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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603227
Report Date: 03/30/2023
Date Signed: 03/30/2023 04:49:18 PM

Substantiated


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
03/22/2023 and conducted by Evaluator Angelica Rea
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230322135542
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:
03/30/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Luther WatersTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Facility's staff are verbally and emotionally abusing clients in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angelica Rea conducted a visit in response to the above allegations. On today's visit, LPA met with Administrator, Luther Waters who assisted with today's visit.

Regarding the allegation that facility's staff are verbally and emotionally abusing clients in care, the investigation consisted of interviews with Administrator, Staff #1, Staff #2 and residents #1 - #3. LPA also reviewed resident #1's Individual Program Plan, and spoke to Lanterman service coordinator. The investigation revealed that Staff #1's relative passed away in early March 2023. Administrator and Staff interviewed, stated that resident #1 heard that staff #1's resident passed away and made inappropriate comments regarding staff #1's relative. Staff #1 admitted that he did curse at resident #1 on 3/8/2023. Staff #1 said that he was placed on leave for a week. Residents interviewed were unable to corroborate the allegation. They stated that staff treat them well. Resident #1 stated that he has a recording of the incident on his cell phone. LPA listened to the recording on resident #1's phone.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 28-AS-20230322135542
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: 03/30/2023
NARRATIVE
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Based on LPA's observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
03/22/2023 and conducted by Evaluator Angelica Rea
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230322135542

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:
03/30/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Luther WatersTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Facility staff is not feeding client in care
INVESTIGATION FINDINGS:
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Regarding the allegation that facility staff is not feeding clients in care, the investigation consisted of interviews with Administrator, Staff #1, Staff #2 and residents #1 - #3. LPA also reviewed resident #1's Individual Program Plan, and spoke to Lanterman service coordinator.

Administrator and staff interviewed denied the allegation. They stated that staff feed all clients in care, and the facility always has a sufficient amount of food. LPA reviewed food supply, and observed that facility has a sufficient amount of perishable and non perishable food. Residents interviewed were unable to corroborate the allegation. Two out of three residents stated that the staff do provide them with meals, and they enjoy the food that is served.

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 and a copy of this report was provided to Mr. Waters.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20230322135542
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/14/2023
Section Cited
CCR
80072(a)(1)
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(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.
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Administrator will ensure that clients personal rights are not violated. Administrator will provide staff training to all facility staff, and will provide proof of training to LPA by POC due date.
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This requirement is not being met as evidenced by: Staff #1 admitted to cursing at resident #1 on 3/8/23. This poses a risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4