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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603260
Report Date: 01/23/2024
Date Signed: 01/23/2024 02:39:35 PM

Document Has Been Signed on 01/23/2024 02:39 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: 4CENSUS: 4DATE:
01/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Luther Waters, AdministratorTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection on 1/23/24. LPA arrived unannounced and met with Administrator, Luther Waters. The purpose for the visit was explained. The facility is licensed for (4) ambulatory adults ages 18 to 59. The facility is vendorized by the Frank D. Lanterman Regional Center.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tool during the inspection today. The following were observed:
Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves when necessary to assist clients. Staff are continuing to clean and disinfect each shift.
Physical Plant & Environment Safety: The facility does not have any pool or bodies of water on the premises. There are 4 client bedrooms, 3 bathrooms, living room, dining room, kitchen, family room, laundry area, and an attached garage. Each client bedroom has the required furniture and bedding. There are no items obstructing the hallways or walkways. Extra hygiene supplies are locked. Facility has interconnected smoke and carbon monoxide combo detectors throughout the house. Knives and cleaning solutions are locked in the kitchen area. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F.
Operational Requirements: There are currently 4 clients residing at the home. Proper care and supervision is being provided to the clients.
Staffing: There is sufficient staffing at the facility. Facility has an awake staff for the overnight shift.
Personnel Records-Training: Staff files are maintained at the facility. Administrator (Luther Waters) certificate expires on 5/31/24. Staff have current CPR/first aid training and sufficient on-going training that meets the annual requirement. LPA reviewed (3) personnel files. They all have the required documentation on file and fingerprint cleared. Staff have current CPR & First Aid certificates.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2024
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: 01/23/2024
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Clients Rights - Information: Client rights are posted at the facility. Facility provides internet for client to use.
Client Records-Incident Reports: Client files are maintained at the facility. LPA reviewed (3) client files and they have the required documentation including current Individual Program Plan. There are no clients with a restricted health condition and all are ambulatory.
Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. Client are provided with at least 3 meals per day.
Health-Related Services: Medications are centrally stored and locked in one of the kitchen cabinets. The facility document medications daily. LPA reviewed medications for 3 clients and they are being administered as prescribed by the physician.
Incidental Medical & Dental: There are no clients receiving home health services or has a health condition that needs to be monitored more carefully.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Staff are provided training on the emergency procedures annually and know where the utility shutoff valves are located. Facility conducts monthly drills and are documented.
Emergency Intervention: Staff have current CPI training. Per the administrator, staff do not utilize manual restraints at the home.

No deficiency was issued today. An exit interview was held. A copy of this report was given to the administrator.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
LIC809 (FAS) - (06/04)
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