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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603227
Report Date: 09/09/2024
Date Signed: 09/09/2024 03:44:56 PM

Document Has Been Signed on 09/09/2024 03:44 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/
DIRECTOR:
WATERS, LUTHERFACILITY TYPE:
735
ADDRESS:2177 WHITE STTELEPHONE:
(626) 696-3910
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 3CENSUS: 3DATE:
09/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:36 PM
MET WITH:Jaron Pryor - Direct Support Staff TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met Jaron Pryor and explained the reason for 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 facility is located in a residential neighborhood and consist of a kitchen, a living room, a dining room, a TV area, 3 bedrooms, 2 bathrooms, a back yard, front porch, and a detached garage.

LPA conducted a tour of the facility with Jaron Pryor and observed the following:
Facility is in good repair indoor and outdoor. Each common area has furniture in good repair. Kitchen area is clean and cleaning solutions and sharps are kept locked/inaccessible to the clients. Food supplies were observed sufficient for at least 2 days of perishables and 7 days of non-perishables. LPA observed 2 out of the 3 clients bedroom which have the required furniture, sufficient lighting and bedding supplies. LPA did not observed the third room due to client's personal choice. Two bathrooms were observed each in working condition, water temperature was tested between 107.0 - 107.1 degrees F. which is within the required 105-120 degrees F. Backyard provides a covered seating area, no large bodies of water were observed. Carbon Monoxide/Smoke detectors were observed in working condition. Fire extinguisher was observed. First Aid kit was reviewed.
LPA reviewed medication and files for 3 clients. Only 1 client is assisted with P&I money which was reviewed. LPA reviewed files for 5 staff. Administrator certificate #6016539735 exp. date: 5/31/24. Administrator submitted documents for renewal on 5/1/24.

Infection Control Plan and Emergency Disaster plan were reviewed.

No deficiencies were noted during this visit.

Exit interview was conducted with Jaron Pryor and a copy of this report was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2024
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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