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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221453
Report Date: 04/12/2022
Date Signed: 11/10/2022 09:11:51 AM

Document Has Been Signed on 11/10/2022 09:11 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:LUNDY FAMILY CARE HOMEFACILITY NUMBER:
191221453
ADMINISTRATOR:LUNDY, DWYANEFACILITY TYPE:
735
ADDRESS:964 SUMMITTELEPHONE:
(626) 794-5124
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 4CENSUS: 4DATE:
04/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Administrator / Dwayne LundyTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced site visit for the Required - 1 Year inspection. Upon arriving at the facility, LPA met with Administrator / Dwayne Lundy who assisted with the visit. The facility is licensed to serve four (4) Developmentally Disabled Clients ages 18 - 59 years. The facility has an approved fire clearance for four (4) Ambulatory Clients only. Currently, there are four (4) clients in placement.

During today's visit, LPA toured the physical plant areas (outside only) to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility is located in a residential area. The front yard is well landscaped with steps and/or a ramp that leads to the entry. A shaded area with chairs is provided in the back yard. The trash cans have covered lids. There are no weapons on the premises. Security bars were observed on the windows of the facility with a safety release device. There is a detached two-car garage which is being used as a storage.

Due to time constraints, LPA had to terminate visit and will return on a later date to complete the Required - 1 Year inspection.
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No deficiencies were observed during today's visit.
An exit interview was conducted and a copy of this report was provided to the Administrator.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2022
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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