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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603260
Report Date: 12/03/2022
Date Signed: 12/03/2022 02:41:54 PM

Document Has Been Signed on 12/03/2022 02:41 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 PLACE IIFACILITY NUMBER:
198603260
ADMINISTRATOR:WATERS, LUTHERFACILITY TYPE:
735
ADDRESS:761 BOYLSTON STREETTELEPHONE:
(323) 491-6572
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 3CENSUS: 3DATE:
12/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Lead DSP, Emon Davis-DollyTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an annual inspection focusing on Infection Control Practice domain. LPA Pena met with Lead DSP, Emon Davis-Dolly and explained the purpose of today's visit. LPA was screened and asked to sign the visitor's log in sheet upon entry to the facility. The facility is approved for three (3) Developmentally Disabled Adults, ages 18-59, of which only one (1) may be non-ambulatory. There are currently three (3) ambulatory clients residing at the home. The home is vendorized by Frank D. Lanterman. LPA observed the facility plant, COVID-19 procedures, reviewed residents' medications and observed food supply. This facility is a single-story home located in a residential area. There are three (3) bedrooms, three (3) bathrooms, one (1) office, living room, dining room, family room, kitchen, laundry space, and an attached garage.

LPA along with the Lead DSP toured the facility and observed/inspected the following:
  • The facility had a universal entrance screening area including a sign-in sheet, thermometer, and hand sanitizer. A temperature check log for staff and clients was maintained daily.
  • Lead DSP screened, took the temperature of LPA and asked to sign in the visitor's log in sheet upon arrival.
  • COVID-19 signage was placed in several areas including entrance and common areas.
  • Lead DSP on duty wore face mask.
  • Facility has 30 days of PPE supplies.
  • There are three (3) bedrooms designated for clients and 1 used as an office. All client rooms are equipped with the required furnishings.
  • Kitchen was inspected at 1:45pm. Knives and medications are locked in a kitchen cabinet.
  • Smoke detector is working at the time of visit.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 PLACE II
FACILITY NUMBER: 198603260
VISIT DATE: 12/03/2022
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  • Cleaning solutions are stored and locked under the kitchen sink.
  • Sufficient food supply of 2-day perishable and 7-day nonperishable were observed.
  • Laundry room is located inside the house and is clean and has cleaning supplies inaccessible to clients.
  • There are three (3) fire extinguishers that are fully charged, located in the kitchen, laundry area and garage.
  • Hot water temperature was measured within the required range of 105-120 degree Fahrenheit. Kitchen hot water temperature read at 105.2 deg F, Bathroom #1 read at 108.9 deg F, bathroom #2 read at 114.6 deg F and bathroom #3 read at 117.9 deg F.
  • The backyard has shaded area with tables and chairs for clients use.
  • There are no obstructions to the passageways or bodies of water at the facility.
  • There are no cameras in the facility.
  • Medications were reviewed for all 3 clients and did not observe any discrepancies.
  • Medications are documented properly and given as prescribed using an app called THERAP.
  • First Aid kit is complete.
  • Staff and resident files were not reviewed during today's visit.

No deficiencies were issued during the visit today. Exit interview was conducted and a copy of this report was given to the Lead DSP, Emon Davis-Dolly.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2022
LIC809 (FAS) - (06/04)
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