<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603227
Report Date: 08/10/2023
Date Signed: 08/10/2023 02:29:23 PM

Document Has Been Signed on 08/10/2023 02:29 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:WATERS PLACEFACILITY NUMBER:
198603227
ADMINISTRATOR:WATERS, LUTHERFACILITY TYPE:
735
ADDRESS:2177 WHITE STTELEPHONE:
(626) 696-3910
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 3CENSUS: 3DATE:
08/10/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:46 PM
MET WITH:Luther Wathers - AdministratorTIME COMPLETED:
02:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit to provide deficiencies revealed during a complaint investigation. LPA met with Luther Waters Administrator and explained the reason for the visit.

During complaint # 28-AS-2023032911250 investigation, Administrator stated Client #2 (C2) had been showing inappropriate behaviors towards client #1(C1) for at least six months. On 2/9/23 C2 touched C1’s chest and rear end and on 3/21/23 C2 touched C1’s chest area. This was reported to the department via fax. During the investigation another client (C3) living at the facility stated to have experience C2’s touching as well. Both clients stated to have requested C2 to stop such behavior as it was unwanted by them. Facility has provided staff supervision and redirected C2’s behavior each time. However, the facility did not have a written plan in place to prevent the behavior from continuing. Last Triennial Individual Plan was conducted on 8/12/19 and reviewed by LPA. During the complaint investigation visit Triennial Individual Plan dated 8/12/19 was the most current service plan on file for C2.


Deficiencies have been noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 08/10/2023 02:29 PM - It Cannot Be Edited


Created By: Mary G Flores On 08/10/2023 at 01:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WATERS PLACE
FACILITY NUMBER: 198603227

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/11/2023
Section Cited
CCR
80072(a)(1)

1
2
3
4
5
6
7
80072 Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons.
This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator will certify on LIC 9098 that will ensure to create a plan in writting for clients when an incident occurs. LIC 9098 is to be submitted by POC due date 8/11/23.
8
9
10
11
12
13
14
Based on interviews conducted licensee failed to ensure C2 stopped touching C1's chest area for about six months which poses an immediate risk to the health, safety, or personal rights to the persons in care.
8
9
10
11
12
13
14
Type B
08/17/2023
Section Cited
CCR85068.3(a)

1
2
3
4
5
6
7
85068.3 Modifications to Needs and Services Plan (a)... Needs and Services Plan... shall be updated as frequently as necessary to ensure... document significant occurrences that result in changes in the client's..., mental and/or social functioning.
This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator will obain a copy of current triennal individual plan for C2 and submitted to the department by POC due date 8/17/23.
8
9
10
11
12
13
14
Based on documents reviewed licensee did not ensure to update Triennial Individual Plan dated: 8/12/19 for C2 which poses a potential risk to the health, safety, or personal rights of the persons in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2