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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603227
Report Date: 03/29/2023
Date Signed: 03/29/2023 04:23:40 PM

Document Has Been Signed on 03/29/2023 04:23 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:
03/29/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:53 PM
MET WITH:Luther Waters - Administrator TIME COMPLETED:
04:35 PM
NARRATIVE
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Licensing program analyst(s)(LPA) Mary Flores conducted a case management visit at the facility during a complaint investigation visit. LPA Flores met with Luther Waters administrator and explained the reason for the visit.

During a health and safety check visit for a complaint conducted on 3/29/23 by LPA Flores and Justin Willard staff the following was observed:

Water temperature was tested in bathroom #1(B1) tested at 91.4 degrees F., which is not within the required water temperature 105-120 degrees F. Cleaning supplies were observed under the sink in B2 without a lock.

Deficiencies were cited in 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: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2023
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 03/29/2023 04:23 PM - It Cannot Be Edited


Created By: Mary G Flores On 03/29/2023 at 04:00 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: 03/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/30/2023
Section Cited
CCR
80087(g)

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Buildings and Grounds: (g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidence by:
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Administrator will ensure all cleaning supplies are inaccessible to the clients at all times. Certify by LIC 9098 and submit to the department by POC due date 3/30/23.
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Based on observation licensee did not ensure cleaning supplies were kept inaccessible to the clients in B#2 had cleaning supplies in the cabinet without a lock which poses an immediate risk to the safety, health, or personal rights of the persons in care.
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Type B
04/05/2023
Section Cited
CCR80088(e)(1)

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800088 Furniture, Fixtures, Equipment, and Supplies: (e) Faucets used... for personal care...shall deliver hot water.(1)...be maintained to automatically regulate temperature...to attain a hot water temperature of not less than 105 degrees F and not more than 120 degrees F.
This requirement is not met as evidence by:
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Administrator will ensure water temperature is within the required 105-120 degrees F. at all times and will submit a daily log for the next 7 days of water temperature in B#2 and will submit the log to the department by POC due date: 4/5/23.
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Based on observation licensee did not ensure water temperature in B2 was within the required 105-120 degrees F. Water was tested in B2 at 91.4 degrees F. which poses a potential risk to the health, safety, or personal rights risk to the persons 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.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2023


LIC809 (FAS) - (06/04)
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