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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221453
Report Date: 04/03/2025
Date Signed: 04/03/2025 03:49:38 PM

Document Has Been Signed on 04/03/2025 03:49 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/
DIRECTOR:		LUNDY, DWYANEFACILITY TYPE:
735
ADDRESS:964 N SUMMIT AVE.TELEPHONE:
(626) 794-5124
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 4CENSUS: 4DATE:
04/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:Dwayne Lundy - Administrator
Jayde Prentis - DSP I		TIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit. LPA was met by Jayde Prentis - DSP I and explained the purpose of today's visit. At 2:30pm, Administrator arrived and assisted LPA with the inspection. The facility is licensed to serve developmentally disabled adults ages 18-59 years old, ambulatory only and services provided by Frank D. Lanterman Regional Center. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Staff are adhering to infection control requirements, using appropriate hand hygiene and gloves while assisting clients' medications. The facility has an Infection Control Plan maintained at the facility.

Physical Plant & Environment Safety: 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 office/storage room, laundry area, front yard, back yard and detached garage. Note: the facility is licensed for only the first level. The 2nd level is is inaccessible to clients, currently under construction which used to be a storage area.
Currently, there are (4) clients residing in the home. Client bedrooms were toured. Each bedroom has a bed, linen, dresser, light and sufficient closet space. Smoke alarms and carbon monoxide were tested and operable. Laundry area is next to the kitchen area. Knives, cleaning solutions, and disinfectants are locked in a cabinet and inaccessible to clients. There are no firearms or weapons stored at the facility. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. LPA observed broken door blinds on the entry door and an open trash bin overflowing with empty bottles. The office/storage room appeared messy, disorganized, cluttered with clothes on the ground and filled plastic bags scattered throughout the room. Trash bins in the home do not have lids. There are (3) fire extinguishers which were last serviced on 02/07/2024. Exit doors are free of any obstruction and there are no pools or large bodies of water. The backyard was inspected and LPA observed broken door blinds on the entry door and an open trash bin overflowing with empty bottles. The office/storage room appeared messy, disorganized, cluttered with clothes on the ground and filled plastic bags scattered throughout the room. Trbserved various building materials like pieces of wood in different sizes, cans of paint in the backyard. LPA observed a sitting space in the backyard but no shaded area. *****CONTINUED ON LIC809-C*****
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2025
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 7
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 04/03/2025
NARRATIVE
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Operational Requirements: A fire clearance is in place. Surety bond will be reviewed on the next visit. Emergency fire and earthquake drills are conducted every (6) months. Disaster drill was conducted on 03/01/2025.

Food Service: There is sufficient food supplies of 2-day perishable and 7-day supplies of non-perishable items. The food is properly stored in the refrigerator. There are (2) clients with special diets residing at this facility. Pesticides and cleaning supplies are kept away from the food preparation areas.

Health Related Services: The medications are centrally stored and in their original containers. LPA reviewed medication for (4) clients. The facility uses Medication Administration Record (MAR) to document medications given. Medications are administered as prescribed by the Physician, however LPA observed (3) medications missing for one of the clients (Client #1).

Due to time constraints, this annual inspection will have to be continued at a later date. LPA will inspect/review (7) domains: Staffing, Personnel Records-Training, Client Records-Incident Reports, Client Rights-Information, Incidental Medical & Dental, Disaster Preparedness and Emergency Intervention.

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.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 04/03/2025 03:49 PM - It Cannot Be Edited


Created By: Bennette Pena On 04/03/2025 at 03:19 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: LUNDY FAMILY CARE HOME
FACILITY NUMBER: 191221453

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
80087 Buildings 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, the licensee did not comply with the section cited above in that LPA observed broken door blinds on the entry door and an open trash bin overflowing with empty bottles. The office/storage room appeared messy, disorganized, cluttered with clothes on the ground and filled plastic bags scattered throughout the room and the backyard have various building materials like wood and cans of paint which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 04/17/2025
Plan of Correction
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Licensee shall ensure that the facility shall be clean and sanitary at all times. Licensee will send photos that the door blinds have been replaced, trash bins emptied, the office/storage room is organized and the various building materials, like wood and cans of paint have been disposed. Proof will be submitted to LPA/CCL by POC due date.
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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/03/2025 03:49 PM - It Cannot Be Edited


Created By: Bennette Pena On 04/03/2025 at 03:25 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: 04/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
80020 Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in that LPA observed (3) fire extinguishers mounted on the wall in the dining area, near the kitchen and in the den which were last serviced on 02/07/2024 which poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 04/04/2025
Plan of Correction
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Licensee will send proof that the fire extinguishers have been inspected/serviced and/or replaced and submit to LPA/CCL by POC due date.
Type A
Section Cited
CCR
80075(k)(1)
80075 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, interview, record review, the licensee did not comply with the section cited above in that LPA observed (3) medications missing for Client #1 which poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 04/04/2025
Plan of Correction
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Licensee shall investigate the whereabouts of the missing medications for Client #1 and provided an explanation to the department. If medications are not found, Licensee shall order and replace missing medications immediately and provide proof to the department 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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2025


LIC809 (FAS) - (06/04)
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