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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603388
Report Date: 01/28/2022
Date Signed: 01/28/2022 12:28:22 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 3DATE:
01/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Oneisha James, AdministratorTIME COMPLETED:
12:26 PM
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Kiley Johnson and explained the purpose of the visit. Administrator Oneisha James arrived shortly after. The home is a level 4 home. There are 3 residents 18 - 59 residing at facility. The facility consists of a living room, dining area, kitchen, laundry room, two bedrooms with attached bathrooms, one bedroom, one full bathroom and administrator office, the client bedrooms are spacious and will easily accommodate the client's furnishings. The passageways, walkways, driveways, steps and patios are free from obstructions. The front, back and side areas are free of hazards. The last fire drill was completed on January 13, 2022. Oneisha James Administrator certificate expires May 22, 2022. Abiola Quadri Administrator certificate expires 12/09/2022
The following were observed/inspected:

· COVID-19 signs are posted at the entrance. Visitors are screened in the main entrance and a log is kept.
· Infection control signs and other COVID-19 signs are posted throughout the facility in the bathrooms, kitchen, and hallway to promote hand washing, cough/sneeze etiquette, and physical distancing.
· Facility has one designated isolation room.
· Three (3) client rooms, common areas, bathrooms, and outdoor physical plant was inspected.
· Fscility is equipped with alcohol-based hand sanitizer.
· Three (3) centrally stored client medication records were reviewed.
· Staff responsible for direct care and supervision were observed wearing masks.
· Clients were not observed wearing masks but adhering to public health social distance guidelines.
· Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
· A posted Emergency Disaster Plan was observed.
· PPE's were observed.
· Staff and resident files were not reviewed during today's visit.
·
No deficiencies cited.

Exit interview was conducted with Assistant Administrator Oneisha James. A copy of the report was provided.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022
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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