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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603388
Report Date: 11/08/2024
Date Signed: 11/08/2024 12:53:49 PM

Document Has Been Signed on 11/08/2024 12:53 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
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:
(562) 884-4903
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 4CENSUS: 4DATE:
11/08/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:51 AM
MET WITH:Manager Trinitta Allen TIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Tyler Reyes and Luis Deleon conducted an unannounced case management visit to conduct a Health and Safety Check. LPAs met with Manager Trinitta Allen and the purpose of the visit was discussed. The facility is licensed for (4) ambulatory adults ages 18 to 59.

On today’s visit LPAs conducted a health and safety check. LPAs toured the physical plant and observed the following: living room, staff office, kitchen, dining area, (3) client bedrooms, (3) restrooms (2 of the client bedrooms have a private restroom and 1 restroom is for common use), laundry area, detached garage, front and backyard. LPAs observed with Manager Trinitta in restroom #1 located adjacent to the dining area, the hot water knobs on the double vanity sink are non-functional. Manager Trinitta states that the hot water knobs of restroom #1 have been non-funtional for approximately (1) one month. LPAs observed with Manager Trinitta client #1 (C1) private restroom #2 the hot water measured at 128.1 degrees f. The private restroom #3 located in C2 and C3’s room measured at 140.9 degrees f. The water temperature was retested with facility thermometer and tested above 120 degrees in restroom #2 and restroom #3 .The water temperature in all (3) restrooms did not meet Title 22 regulations, which require a range of 105 – 120 degrees f. During a tour of the backyard LPAs observed with Manager Trinitta cat feces in the backyard area on both sides of the detached garage. Based on record review the facility does not have a surety bond on file while they do handle the money of the clients. The facility was missing a Physician’s Report for both C3 and C4.

Oneisha James cooperate board member of Worchester Home will submit the necessary documents to be reviewed for change of administrator. LPAs provided Oneisha with the Monterey Park Regional office fax number and assigned LPA’s contact information.

Deficiencies issued on LIC809-D. An exit interview was conducted, and a copy of this report was provided to
to Oneisha James with the Appeals Rights.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Tyler Reyes
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2024
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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Document Has Been Signed on 11/08/2024 12:53 PM - It Cannot Be Edited


Created By: Tyler Reyes On 11/08/2024 at 12:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WORCHESTER HOME
FACILITY NUMBER: 198603388

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/11/2024
Section Cited
CCR
80088(e)(1)

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80088 (e)Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement
is not met as evidence by.

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Administrator will maintain water temperature between 105 - 120 degrees F, Administrator will develop a water log and record water temeratures every 24 hrs for the next 5 calendar days. Documents will be submitted to CCL by POC Due Date
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Based on observations, the licensee did not comply with the section cited above LPAs observed with Manager Trinitta client #1 (C1) private restroom #2 the hot water measured at 1218.1 degrees f. The private restroom #3 located in C2 and C3’s room measured at 140.9 degrees f. which poses an immediate health risk to persons in care.
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Type A
11/11/2024
Section Cited
CCR80087(a)

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80087 (a)The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement
is not met as evidence by.
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Administrator will ensure the backyard is clean and sanitary for clients. The In-Service Training on keeping backyard free from animal feces and will include list of attendees’ names and attendees’ signatures. Documents will be submitted to CCL by POC Due Date
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Based on observations, the licensee did not comply with the section cited above During a tour of the backyard LPAs observed with Manager Trinitta cat feces in the backyard area on both sides of the detached of the garage which poses an immediate health risk to persons in care.
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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:Fernando Fierros
LICENSING EVALUATOR NAME:Tyler Reyes
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/08/2024 12:53 PM - It Cannot Be Edited


Created By: Tyler Reyes On 11/08/2024 at 12:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WORCHESTER HOME
FACILITY NUMBER: 198603388

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2024
Section Cited
CCR
80087(a)

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80087 (a)The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement
is not met as evidence by.
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The Administrator ensure that restroom #1 is in good repair and will submit proof the hot water knobs has been fixed. Administrator will develop a water log and record water temeratures every 24 hrs for the next 5 calendar days. Documents will be submitted to CCL by POC Due Date
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Based on observations, the licensee did not comply with the section cited above LPAs observed with Manager Trinitta in restroom #1 located adjacent to the dining area, the hot water knobs on the double vanity sink are non-functional. Manager Trinitta states that the hot water knobs of restroom #1 have been non-funtional for approximately (1) one month poses a potential health, safety or personal rights risk to persons in care.
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Type B
11/15/2024
Section Cited
CCR80025(b)

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80025 (b)All licensees, other than governmental entities, who are entrusted to care for and control clients' cash resources shall file or have on file with the licensing agency, a bond issued by a surety company to the State of California as principal. This requirement
is not met as evidence by.
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Administrator is to ensure that the facility obtains a surety bond due to their handling of the clients cash resources. Documents will be submitted to CCL by POC Due Date
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Based on record review, the licensee did not comply with the section cited above they do not have a surety bond on file while they do handle the money of the clients, which poses a potential health, safety or personal rights risk to persons in care.
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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:Fernando Fierros
LICENSING EVALUATOR NAME:Tyler Reyes
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/08/2024 12:53 PM - It Cannot Be Edited


Created By: Tyler Reyes On 11/08/2024 at 12:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WORCHESTER HOME
FACILITY NUMBER: 198603388

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2024
Section Cited
CCR
80069(b)

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80069 (b) In ARFs , prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.
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Administrator to provide LPA with a copy of Pysician Report for C3 and C4. Documents will be submitted to CCL by POC Due Date
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Based on record review the licensee did not comply with the section cited above C3 and C4 are missing Physician's Report which poses a potential health, safety or personal rights risk to persons in care.
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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:Fernando Fierros
LICENSING EVALUATOR NAME:Tyler Reyes
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2024


LIC809 (FAS) - (06/04)
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