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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603388
Report Date: 12/12/2024
Date Signed: 12/13/2024 10:57:50 AM

Document Has Been Signed on 12/13/2024 10:57 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:WORCHESTER HOMEFACILITY NUMBER:
198603388
ADMINISTRATOR/
DIRECTOR:		QUADRI, ABIOLAFACILITY TYPE:
735
ADDRESS:790 WORCHESTER AVETELEPHONE:
(626) 314-3128
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 4CENSUS: 4DATE:
12/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Oneshia James, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Sanjay Vaid conducted the required annual inspection. LPA arrived unannounced and met with Nika Laguna Direct Staff Person (DSP) Administrator, Oneisha James arrived shortly after. 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 while assisting clients. Staff are cleaning and disinfecting daily and as needed.
Physical Plant & Environment Safety: The facility does not have any pool or bodies of water on the premises. There are 3 client bedrooms, 3 bathrooms, living room, dining room, and kitchen. Each client bedroom has the required furniture and bedding. Extra hygiene supplies were observed locked. Facility has an operable smoke and carbon monoxide combo detector in each room. Knives, cleaning solutions, and disinfectants are locked, not accessible to clients. 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. The fire extinguisher was last inspected on 02/03/24.
Operational Requirements: There are currently 4 clients residing at the home.
Staffing: There is sufficient staffing at the facility. One client requires one-to-one staff. Facility has an awake staff for the overnight shift.
Personnel Records-Training: Staff files are maintained at the facility. Administrator (Oneisha James) certificate expires on12/07/2025. Staff have current CPR/first aid training and sufficient on-going training that meets the annual requirement. LPA reviewed (4) personnel files and they all have required documentation. One of the staff was not fingerprint cleared.

con't 809C....
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: WORCHESTER HOME
FACILITY NUMBER: 198603388
VISIT DATE: 12/12/2024
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Clients Rights - Information: Client rights are posted at the facility. Facility provides internet access device for client use.
Client Records-Incident Reports: Client files are maintained at the facility. LPA reviewed all (4) 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. Freezers are maintained at a temperature of 0 degree F and the refrigerator at a maximum of 45 degrees F. Both are kept clean and food are properly stored.
Health-Related Services: The medications are centrally stored and locked. The facility uses the Medication Administration Record (MAR) log to document medications given. LPA reviewed medications for all 4 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 posted with contact numbers and at least 2 relocation sites. Staff are provided training on the emergency procedures and know where the utility shutoff valves are located.
Emergency Intervention: Staff have CPI training and are up-to-date. Their CPR/first aid certificates have not expired. The staff will only use manual restraint as the last resort.

No deficiency found on today’s visit. An exit interview was held. A copy of this report were given to the administrator.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC809 (FAS) - (06/04)
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