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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603260
Report Date: 10/30/2023
Date Signed: 10/30/2023 09:02:15 AM

Document Has Been Signed on 10/30/2023 09:02 AM - 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:
10/30/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:24 AM
MET WITH:Emon Davis-DollyTIME COMPLETED:
09:10 AM
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LPA Ramirez made an unannounced Case Management visit on 10/30/23 and was met by Direct Support Staff (DSP) Emon Davis-Dolly and explained the purpose of the visit. Administrator Luther Waters arrived shortly after to assist in tour.

LPA Ramirez arrived to the facility at 8:15 am to conduct a facility tour due to facility request to increase in capacity from three (3) to four (4). LPA Ramirez toured four (4) client bedrooms which are all approved for ambulatory use only. LPA Ramirez reviewed 850 Fire Clearance approved by Pasadena Fire Department on 10/3/23 for four (4) ambulatory only. LPA Ramirez will change facility capacity from three (3) to four (4) and an updated facility license will be issued to reflect change.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2023
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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