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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603260
Report Date: 01/28/2022
Date Signed: 01/28/2022 04:37:28 PM

Document Has Been Signed on 01/28/2022 04:37 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:WATERS PLACE IIFACILITY NUMBER:
198603260
ADMINISTRATOR:WATERS, LUTHERFACILITY TYPE:
735
ADDRESS:761 BOYLSTON STREETTELEPHONE:
(323) 491-6572
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 3CENSUS: 3DATE:
01/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Luther Waters, Licensee TIME COMPLETED:
04:39 PM
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced annual inspection. LPA met with Cori Waters who stated is lead at facility. Licensee Luther Waters arrived a short time later. The facility has an approved fire clearance for two (2) ambulatory residents, one (1) non-ambulatory and zero (0) bedridden. All three current clients are ambulatory. The facility is a single-story home with three (3) client’s bedrooms, three (3) clients' bathrooms, a den, a kitchen, a dining room, a living room, administrator office, and a laundry room. The facility is in a residential neighborhood. This facility last fire drill was on 12/15/2015 Co- Administrator Cori Waters certificate has expiration date of 07/30/22

LPA took a tour of the physical plant including the inside and outside of the house.

The following were observed/inspected:
· COVID-19 signs are posted at the entrance. Visitors are screened in the main entrance and a log is kept.
· Infection control signs and other COVID-19 signs are posted throughout the facility in the bathrooms, kitchen, and hallway to promote hand washing, cough/sneeze etiquette, and physical distancing.
· Facility has designated isolation room.
· Three (3) client rooms, common areas, bathrooms, and outdoor physical plant was inspected.
· Facility is equipped with alcohol based hand sanitizer.
· Three (3) centrally stored client medication records were reviewed.
· Staff responsible for direct care and supervision were observed wearing masks.
· Clients were observed wearing masks but adhering to public health social distance guidelines.
· Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
· A posted Emergency Disaster Plan was observed.
· PPE's were observed.
· Staff and resident files were not reviewed during today's visit.
No deficiencies cited.
·
Exit interview was conducted with Assistant Administrator Luther Waters. A copy of the report was provided.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2022
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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