198603388-1-16-2024-28-AS-CDCN-CZJVMH-20240116153334

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603388
Report Date: 01/16/2024
Date Signed: 01/16/2024 03:33:44 PM

Document Has Been Signed on 01/16/2024 03:33 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 HOME		FACILITY NUMBER:	198603388
ADMINISTRATOR:	QUADRI, ABIOLA		FACILITY TYPE:	735
ADDRESS:	790 WORCHESTER AVE		TELEPHONE:	(562) 884-4903
CITY:	PASADENA	STATE: CA	ZIP CODE:	91104
CAPACITY:	4	CENSUS: 3	DATE:	01/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Oneisha James, Administrator		TIME COMPLETED:	03:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection on 1/16/24. LPA arrived unannounced and met with Administrator, Oneisha James. 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. Facility has sufficient PPE supplies and still screening for COVID-19 symptoms. 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 10/19/23. Operational Requirements: There are currently 3 clients residing at the home. One client will be moving in today. Staffing: There is sufficient staffing at the facility. One client requires one-to-one staff. Facility has an awake staff for the overnight shift. (Continue on LIC809C)

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WORCHESTER HOME	FACILITY NUMBER: 198603388
	VISIT DATE: 01/16/2024

NARRATIVE

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Personnel Records-Training: Staff files are maintained at the facility. Administrator (Oneisha James) certificate expires on 5/15/24. 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.
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 (3) 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 3 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.

A deficiency was issued along with a civil penalty for background clearance. An exit interview was held. A copy of this report along with appeal rights were given to the administrator.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/16/2024 03:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80066(a)(12)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) For employees that are required to be fingerprinted pursuant to Section 80019: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in one out of the 4 staff which Staff #2 did not have blackground clearance which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/16/2024
	Plan of Correction
1 2 3 4	The licensee shall ensure Staff #2 obtain a background clearance and associated to the facility prior to coming back to work. In addition, a written statement certifying all employees shall have background clearance prior to working at the facility shall be submitted to LPA by 1/16/24.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024

LIC809 (FAS) - (06/04)

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