198603227-10-20-2022-28-AS-TVAO-CLURM7-20221206120813

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603227
Report Date: 10/20/2022
Date Signed: 10/20/2022 11:58:41 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/08/2022 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20220808162016

FACILITY NAME:	WATERS PLACE		FACILITY NUMBER:	198603227
ADMINISTRATOR:	WATERS, LUTHER		FACILITY TYPE:	735
ADDRESS:	2177 WHITE ST		TELEPHONE:	(626) 696-3910
CITY:	PASADENA	STATE: CA	ZIP CODE:	91107
CAPACITY:	3	CENSUS: 3	DATE:	10/20/2022
		UNANNOUNCED	TIME BEGAN:	10:46 AM
MET WITH:	Luther Waters - Administrator		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Facility is in disrepair (stove)
Staff retaliated against resident for complaining
Staff does not ensure that there is an adequate amount of food in the home

INVESTIGATION FINDINGS:

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Licensing Program Analyst(s) (LPA) Mary Flores conducted a complaint investigation visit regarding the above allegation(s). LPA met with Luther Waters administrator and explained the reason of the visit.

The investigation consisted of the following: On 8/16/22 LPAs Flores and Yang requested a copy of staff/resident roster, conducted a tour of the facility's kitchen with staff Dominique Lauderdale and garage to observe freezer with Jermaine Fletcher staff,(S1),LPAs interview S1, staff #2(S2) and interview administrator over the phone. LPA Flores reviewed files for clients #1(C1),#2(C2),#3(C3) and requested copies of face sheet, individual personal plan, physician's report, and admissions agreement. In addition facility's menu were requested. On 10/20/22 LPA Flores conducted interviews with clients #1(C1) and #2(C2) and observed food supplies. LPA attempted to interview client #3(C3) over the phone. LPA requested copies of house rules and placement agency investigation findings letter.

The investigation revealed the following: Regarding allegation: Facility is in disrepair. It is alleged the facility has no working stove or microwave. (CONTINUED LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220808162016

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WATERS PLACE	FACILITY NUMBER: 198603227
	VISIT DATE: 10/20/2022

NARRATIVE

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Interviews with clients revealed 1 out of 2 clients stated facilities microwave does not work and 1 out of 2 clients stated microwave and stove are in working condition. Interviews with staff revealed 3 out of 3 staff stated the stove and microwave were in working condition. During the tour of the facility on 8/16/22 and 10/20/22 LPA Flores observed stove and microwave in working condition.

Based on interviews, observation, and document review conducted, there was insufficient evidence to prove the allegation(s). Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Regarding allegation: Staff retaliated against resident for complaining. It is alleged staff is threatening the client with having him move out. Interviews with clients revealed 2 out of 2 clients stated administrator has not asked them or others to move out. Interviews with staff revealed 3 out of 3 staff stated clients have not been asked to move out of the facility due to behaviors. Document reviewed revealed no eviction letters in clients files. House Rules were updated on October 2022. Placement agency's investigation report dated 9/27/22 revealed findings regarding abuse allegations on 8/16/22 were unsubstantiated.

Based on interviews, observation, and document review conducted, there was insufficient evidence to prove the allegation(s). Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Regarding allegation: Staff does not ensure that there is an adequate amount of food in the home. It is alleged there was also no food in the home for about a week. Interviews with clients revealed 1 out of 1 client stated there is food at the facility but not prepared for clients and 1 out of 1 client stated 3 meals and snacks are provided at all times. Interviews with staff revealed 3 out of 3 staff stated 3 meals are provided for clients, incidents regarding food have come up with a client due to food preferences. Facility's tour on 8/16/22 and 10/20/22 revealed facility has sufficient food including fruits, vegetables, frozen foods, meets, can foods, and dairy for at least 2 days worth of perishables and 7 days of non-perishables. Menu review revealed there is a variety of meals prepare with a list of grocery items attached per week. Placement agency's investigation report dated 9/27/22 revealed findings regarding lack of food were unsubstantiated.

(CONTINUED LIC 9099C)

NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220808162016

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WATERS PLACE	FACILITY NUMBER: 198603227
	VISIT DATE: 10/20/2022

NARRATIVE

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Based on interviews, observation, and document review conducted, there was insufficient evidence to prove the allegation(s). Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Exit interview was conducted with Luther Waters administrator and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

LIC9099 (FAS) - (06/04)

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