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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603388
Report Date: 10/16/2023
Date Signed: 10/16/2023 10:55:57 AM

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
10/10/2023 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20231010155716
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:
10/16/2023
UNANNOUNCEDTIME BEGAN:
08:26 AM
MET WITH:Abiola QuadriTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff did not ensure that food was accessible to residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 10/16/23 regarding the above allegations. LPA Ramirez was met by Administrator Abiola Quadri and explained the purpose of the visit.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Staff Roster (LIC 500), Resident Roster (LIC 9020), Staff #1 - 2 interviews (S1 – S2), grocery receipts dated 10/4/23, 10/09/23, copy of facility “Grocery Checklist”, copy of facility menu for the month of October 2023, and physical plant tour.

See 9099-C for continuation.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023
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-20231010155716
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: WORCHESTER HOME
FACILITY NUMBER: 198603388
VISIT DATE: 10/16/2023
NARRATIVE
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The investigation revealed the following. Regarding Allegation: Staff did not ensure that food was accessible to residents- It is alleged that on 10/06/2023, facility staff did not ensure any food was accessible to clients. At 8:45 am, LPA Ramirez gained entry into the facility. LPA toured kitchen area with Administrator Quadri. LPA Ramirez observed kitchen area to be free from hazards and accessible. Facility refrigerator was accessible and contained supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises. LPA Ramirez observed one dozen (1) eggs, gallon of milk, large bag of shredded cheese, 5 bananas, 3 apples, several frozen meats and frozen veggies, frozen family size lasagna, several boxes of ice cream bars, various canned goods, sandwich and hot dog bread, and other boxed food items in kitchen area. LPA Ramirez toured garage area and observed five (5) buckets containing a four (4) person emergency food supply. Two (2) out of the two (2) staff interviewed deny this allegation. LPA Ramirez attempted to interview clients in care. Three (3) out of the four (4) in care where at their day program during visit and LPA was unable to interview clients. Client#4 (C4) was not able to be interviewed due to limited verbal skills. 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 Administrator Quadri. No deficiencies are being cited today. A copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2