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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603388
Report Date: 03/19/2024
Date Signed: 03/19/2024 10:20:16 AM

Document Has Been Signed on 03/19/2024 10:20 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
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: 4DATE:
03/19/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:Administrator Abiola QuadriTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced case management visit to conduct a Health and Safety Check regarding an SOC 341 submitted to the department 3/14/24. LPA met with Administrator Abiola Quadri and the purpose of the visit was discussed.

On todays visit LPA conducted a health and safety check. LPA toured the physical plant of the facility and did not observe any blocked passageways or health and safety hazards. LPA observed the food supply and toxins and sharps were locked and inaccessible to clients in care. Water temperature measured within Title 22 regulations. LPA obtained a copy of the following: Staff roster, Client roster, documents from Client #1's (C1) file, documents from Staff #1 (S1) file.

No deficiencies cited on todays visit and a copy of this report was provided

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2024
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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