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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221453
Report Date: 03/30/2023
Date Signed: 03/30/2023 02:28:06 PM

Document Has Been Signed on 03/30/2023 02:28 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
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:
03/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administartor- Dwayne LundyTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Ashley Calderon made and unannounced visit to conduct the Annual inspection focused on domains within the Compliance and Regulatory Enforcement (Care) Tools. Upon arrival LPA met with Administrator Dwayne Lundy.

LPA Calderon along side with Dwayne Lundy used Care Tools and conducted a tour of the facility. Tour consisted of living room, kitchen, dining room, living room, family room, 2 bathrooms, 2 client bedrooms, one staff office room, backyard and detached garage.

Facility is licensed for Adults ages 18 through 59, Ambulatory only. Clients are associated with Frank.D.Latherman Regional Center. During today's visit 1 client present, 3 at day program and 3 staff present. LPA Calderon interviewed (1) client present and interviewed (2) staff.

The following was conducted and inspected:
  • Outdoor and indoor passageways are free of obstruction.
  • Bathrooms were operable,LPA observed tile floor was in disrepair broken, cracked and un-leveled.
  • Hot water measured between Title 22 regulations.
  • Smoke detectors and carbon monoxide were tested / Fire Drill's are done every 6 months.
  • LPA observed 2nd Entrance door/window broken, and front office window broken.
  • Required postings observed.
  • Fire extinguisher located in dining room and is fully charged and serviced..
  • Sufficient supply of extra linen and towels stored inside the family room storage cabinets.
  • Personal hygiene supplies located in staff office room, inaccessible to clients.
  • Facility temperature for clients was maintained at comfortable temperature.
  • Washer/Dryer appliances observed in family room.
  • Backyard has shaded area for clients, no large bodies of water was observed.
  • PPE was observed through out the facility and in the staff office room.
(Continuation on 809-C...)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2023
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: LUNDY FAMILY CARE HOME
FACILITY NUMBER: 191221453
VISIT DATE: 03/30/2023
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KITCHEN:
  • ( 2) Freezers/refrigerators appear sanitary and temperature maintained. There is an extra freezer in the back area near the family room.
  • Sufficient non-perishable and perishable food items for clients in care located in kitchen.
  • Sharps are locked, inaccessible to clients in dining room storage room.

BEDROOMS:
  • Rooms had required furnishing and in good condition.
  • Beds have the required linen/supplies.

MEDICATION:
  • Medications are stored, locked and inaccessible to clients, located in staff office room.
  • Medication and First Aid Kit/ Manual was reviewed.
  • LPA Calderon reviewed (4) client medications and Medication Log. Medications given as prescribed and documented properly.

RECORD REVIEW:
LPA Calderon reviewed Staff and Client files. As a part of the inspection reviewed (4) client records, (3) staff files.
  • Facility Administrator Certificate Renewed on 8/8/22 , LIC9214 was submitted ,CCLD Backed up/ Pending Status.
  • (4) Client file reviewed, no deficiencies.
  • (3) Staff files reviewed, all finger printed and trained, no deficiencies observed.


The following deficiencies are Cited under the California Code of Regulations Title 22 Division 6, see LIC 809D.

An exit interview was conducted with Administrator Dwayne Lundy and a copy of today's reports were provided and appeal rights were given.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/30/2023 02:28 PM - It Cannot Be Edited


Created By: Ashley Calderon On 03/30/2023 at 02:04 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: LUNDY FAMILY CARE HOME
FACILITY NUMBER: 191221453

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(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 evidenced by:
Deficient Practice Statement
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Based on observation 2 window broken ,one located in the front office window, the 2nd facility door and the back bathroom floor cracked/ broken and un-leveled. The licensee did not comply with the section cited above, 4 clients in care are exposed and poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2023
Plan of Correction
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Administrator will send LPA picture / invoices/receipts of replaced materials. Proof of Tiles in bathroom floor replaced, and both windows/door replaced.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Ashley Calderon
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023


LIC809 (FAS) - (06/04)
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