198603260-6-18-2024-28-AS-DSIS-D6JVHA-20240624162648

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603260
Report Date: 06/18/2024
Date Signed: 06/18/2024 01:43:46 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/14/2024 and conducted by Evaluator Christine Wong

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240614135840

FACILITY NAME:	WATERS PLACE II		FACILITY NUMBER:	198603260
ADMINISTRATOR:	WATERS, LUTHER		FACILITY TYPE:	735
ADDRESS:	761 BOYLSTON STREET		TELEPHONE:	(323) 491-6572
CITY:	PASADENA	STATE: CA	ZIP CODE:	91104
CAPACITY:	4	CENSUS: 3	DATE:	06/18/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Luther Waters		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff made inappropriate comment to client in care

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Wong conducted the “Initial 10-Day” visit to ascertain information pertaining to the above-mentioned allegation(s) and to establish the validity of the complaint. LPA met with Administrator Luther Waters who allowed the entry of the facility and assisted with the visit.

The investigation consisted of the following: On today's date: LPA interviewed two clients (C1-C2) in person and one client (C3) via telephone. LPA also interviewed administrator and the executive assistant in the facility, LPA interviewed four staff (S1-S4) via telephone.LPA also obtained some documents for Client#1(C1_ which include: Nurse consultant report ( March, 2024), Incident Report dated on 6/12/24 and 5/11/24, recent Indivdial Program Plan (IPP).

(See LIC9099C for continuation)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 28-AS-20240614135840

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/18/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The investigation revealed of the following: Allegation "Facility staff made inappropriate comment to client in care" It's alleged that S1 said to C1 "if you don't shut up I am going to stuff these underwear up your mouth" while C1 was having a moment. LPA interviewed all three clients and two out of three denied the allegation and reported staff are nice to them and they never witnessed any staff made any inappropriate comments to clients. LPA interviewed staff and they all denied the allegation and reported they never seen any staff was being mean or made inappropriate comments to clients in the facility. The administrator reported that no clients ever complained about any staff who are not nice or being mean to them. Administrator also stated C1 has history of attention seeking, frequent somatic complaints and fabrication and recently the client had been in and out from the hospital due to recent aggressive behaviors.

Based on the documents reviewed, interviews conducted with staff and clients, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted with Luther Waters administrator and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2