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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603227
Report Date: 09/23/2023
Date Signed: 09/23/2023 01:21:27 PM

Document Has Been Signed on 09/23/2023 01:21 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:
09/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:Jason Taylor - Direct Support StaffTIME COMPLETED:
01:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE tool. LPA met with Jason Taylor and explained the reason of the visit.

Facility is licensed to serve one (1) ambulatory and two (2) non-ambulatory clients between the ages of 18 - 59 years old. The home has a kitchen, a living room, a dining room, 3 bedrooms, 2 bathrooms, a back yard, front porch, and a detached garage.

LPA toured the home with Jason Taylor and observed the following:
The home is clean and in good repair outdoors, no large bodies of water in the facility. It is equipped with a sprinkler system and interlace smoke/carbon detector throughout the facility which were tested and working properly. Window in front door was broken cover with styrofoam, a work order is in place for repair. Each bedroom is equipped with sufficient lighting, furniture, and bedding supplies. LPA did not observed bedroom #2 as client did not allow us entry. Bathrooms (2) were observed in working condition and water temperature was tested between 109.9 - 114.7 degrees F., which is within the required 105-120 degrees F. Kitchen was observed clean, in working condition. Cleaning supplies were stored/locked under the sink and on a cabinet on top of the washer. Food was observed sufficient for at least 2 days of perishables and 7 days of non-perishables. Fire extinguisher was observed in the kitchen.
LPA review files for 3 clients and 5 staff. Client #1(C1) does not have a physician's report/TB clearance on file. Staff #3 - #5(S3-S5) do not have a health screening/TB clearance on file, and Staff #2(S2), S3,S5 do not have a CPR/First Aid training.
Emergency disaster plan was review and last fire drill was provided on 9/15/23.

Deficiencies are noted on LIC 809D per Title 22 Regulations.
Exit interview was conducted with Luther Waters administrator 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: 09/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/23/2023 01:21 PM - It Cannot Be Edited


Created By: Mary G Flores On 09/23/2023 at 12:45 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: 09/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 5 staff files reviewed did not have a health screening on file (S2-S5) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2023
Plan of Correction
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Administrator will obtain and submit staff's health screening to the department by POC due date 10/6/23.
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [count] out of 3 out of 5 staff do not have a TB clearance (S2-S5) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2023
Plan of Correction
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Administrator will obtain and submit TB test clearance for S2-S5 to the department by POC due date 10/6/23.
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: 09/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/23/2023 01:21 PM - It Cannot Be Edited


Created By: Mary G Flores On 09/23/2023 at 01:01 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: 09/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [count] out of 3 out of 5 staff do not have a current First Aid/CPR training (S2,S3,S5) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2023
Plan of Correction
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Administrator will ensure staff obtain First Aid/CPR training and will submit a copy of certificate to the department by POC due date 10/6/23.
Type B
Section Cited
CCR
80070(b)(8)
80070 Client Records:(b) Each record must contain information including, but not limited to, the following: (8) Medical assessment, including ambulatory status, as specified in Section 80069.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 3 client files review did not have a medical assessment which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2023
Plan of Correction
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Administrator will obtain a medical assessment for C1 and will submitted to the department by POC due date 10/6/23.
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: 09/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2023


LIC809 (FAS) - (06/04)
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