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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221453
Report Date: 02/02/2024
Date Signed: 02/09/2024 01:07:13 PM

Document Has Been Signed on 02/09/2024 01:07 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: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:
02/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Rose Grant - CaregiverTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and was greeted by Rose Grant (Caregiver) and Dwayne Lundy (Administrator) who later assisted with the visit, the purpose for today’s visit was explained. The facility is licensed to serve 4 ambulatory only clients ages 18-59. The facility currently has 4 clients, all of which are serviced through regional center.

The facility is a two-story home located in Pasadena, Ca. A tour of the facility includes: living room, dining area, kitchen, den, 2 client bedrooms, 2 bathrooms, 1 staff room, laundry area, front yard, back yard and detached garage. Note: the facility is licensed for only the first level, 2nd level is used for storage and is inaccessible to clients.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit todays visit and observed the following:


Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility. Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan and facility maintains the required liability insurance. Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the clients in the case of an emergency. Personnel Records-Training: Staff has criminal record clearance, current First-Aid/CPR/AED training along with training in postural supports, medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 4 staff files with no issues observed. Administrator Dwayne Lundy certificate expires on 8/30/24.Client Records-Incident Reports: Client files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 4 Resident Files with no issues observed.
(continued on 809-C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 02/09/2024 01:07 PM - It Cannot Be Edited


Created By: Tena Herrera On 02/09/2024 at 12:00 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: 02/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as during physical plant tour LPA obsereved cleaning supplies in an unlocked kitchen cabinet, the cleaning closet was also unlocked and there was one client present at the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2024
Plan of Correction
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*Staff immediatly stored cleaning supplies in cleaning closet and locked the cleaning closet during tour*
Administrator/Licensee to retrain staff on proper storage of disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients, and submit training material and training log with participant names, signatures and date training was conducted to LPA via email by 2/23/24.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(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 evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as hot water temperature was tested in both client restrooms and measured above the required range restroom towards rear of facility measured at 163.5 degrees F, and private restroom within client bedroom measured at 161.9 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2024
Plan of Correction
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*Administrator lowered the water temperature during todays visit and water was within the required range by end of visit*
Administrator/Licensee to create a water temperature log, and monitor water temperature for the next 5 consecuitve days beginning 2/10/24 and ending 2/14/24. Log must have reading for morning/day/evening, and have each reading documented with the date and time water was tested. Log must be submitted to LPA by 2/23/24.
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:David Sicairos
LICENSING EVALUATOR NAME:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 02/09/2024 01:07 PM - It Cannot Be Edited


Created By: Tena Herrera On 02/09/2024 at 12:00 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: 02/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as LPA observed an unlocked plastic portable drawer with medication, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2024
Plan of Correction
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*Staff removed medication from plastic drawers that were in the kitchen/dining area and stored them in the staff office room during visit*
Administrator/Licensee to retrain staff in safe keeping of medication. A copy of the training information and training log with participants, their signatures/names and date of traing to be submitted to LPA by 2/23/24.
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:David Sicairos
LICENSING EVALUATOR NAME:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 02/09/2024 01:07 PM - It Cannot Be Edited


Created By: Tena Herrera On 02/09/2024 at 12:00 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: 02/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(b)(1)
Building and Grounds
(b) All clients shall be protected against hazards within the facility through provision of the following: (1) Protective devices including but not limited to nonslip material on rugs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as during visit LPA observed rug in entrance living room to be curled at the ends, LPA observed staff stumble/trip on rugh, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2024
Plan of Correction
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During visit Administrator corrected this citation by placing adhesive material on the rugs corners, which secured the rug to the ground.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as the last emergency dill was conducted in March 2023, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2024
Plan of Correction
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Administrator/Licensee to conducted emergency drill and send a copy of dill log/details to LPA via email by POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024


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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: LUNDY FAMILY CARE HOME
FACILITY NUMBER: 191221453
VISIT DATE: 02/02/2024
NARRATIVE
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Client Rights-Information: Clients are provided with telephone at the facility. Client rights posters and reporting posters are displayed within the facility. Physical Plant & Environment Safety: LPA toured facility, residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The front yard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested in both client restrooms and measured above the required range of 105-120 degrees F, restroom towards rear of facility measured at 163.5 degrees F, and private restroom within client bedroom measured at 161.9 (details will be documented on the 809-D). Cleaning solutions were found in an unlocked kitchen cabinet during visit and the cabinet that holds all other cleaning solutions was observed to be unlocked as well (details will be documented on the 809-D). Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged. Rug in the entrance living room was observed to be curled at the ends during the visit, LPA observed staff stumble because of the rug during visit (details will be documented on 809-D).
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Medication is properly labeled and are centrally stored in a closet and are in their original containers. LPA reviewed 4 clients’ medications and there were no issues observed. During todays visit LPA observed an unlocked plastic portable drawer with medication, staff immediately removed medication and placed inside locked staff room with other medication (details will be documented on the 809-D).Incidental Medical & Dental: All training is documented in the facility personnel files. Staff performance is reviewed annually, and documentation is maintained in the personnel files.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Facility maintains documentation of the required emergency drills, last drill was conducted in March 2023 (details will be documented on 809-D)
Emergency Intervention: Clients at this facility do not need the use of restraints or de-escalation techniques.
Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during todays visit are documented on the 809-D.

Exit interview held and a copy of the report and appeal rights were provided to the Administrator Dwayne Lundy.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024
LIC809 (FAS) - (06/04)
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