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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603388
Report Date: 01/23/2023
Date Signed: 01/23/2023 12:04:56 PM

Document Has Been Signed on 01/23/2023 12:04 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:WORCHESTER HOMEFACILITY NUMBER:
198603388
ADMINISTRATOR:QUADRI, ABIOLAFACILITY TYPE:
735
ADDRESS:790 WORCHESTER AVETELEPHONE:
(562) 884-4903
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 4CENSUS: 4DATE:
01/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Oneisha James, Co-AdministratorTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection with the focus of the Infection Control domain. LPA arrived unannounced and met with Co-Administrator, Oneisha James. The facility is licensed for (4) ambulatory adults, ages 18 - 59. There are currently 4 residing at the facility.

LPA toured the facility and observed the following:
* The facility has 3 client bedrooms, administrator's office, 3 bathrooms (2 rooms with private bathrooms and 1 for common use), living room, dining area, kitchen, laundry area, and a detached garage.
* Proper COVID-19 signage are posted throughout the home and in bathrooms.
* The facility takes the temperature of visitors and staff and documents in a log book.
* Staff were observed wearing face masks while with client(s).
* Sufficient food supplies for 2 day perishable and a week of nonperishable were observed.
* Clients' files are updated and has most current information on file.
* PPE supplies are available at the home.
* Cleaning supplies are stored in a cabinet at the laundry area. Disinfectants are stored where they are inaccessible to clients.
* Knives and sharps are stored in a locked container.
* Medications are centrally stored in the administrator's office and are locked. LPA reviewed all 4 clients' medication and did not observe any deficiencies.
* The fire extinguishers were last inspected on 10/6/22.
* The co-administrator stated they are following the strictest COVID-19 guidance and have backup staff if needed.

There are no deficiencies issued on the visit today. An exit interview was conducted and a copy of this report is provided to the Co-Administrator.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2023
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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