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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221453
Report Date: 10/05/2022
Date Signed: 10/05/2022 03:07:55 PM

Document Has Been Signed on 10/05/2022 03:07 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
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:
10/05/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Dwayne LundyTIME COMPLETED:
03:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Caregiver Cynthia McNabb and explained the purpose of the visit.
Shortly thereafter Administrator Dwayne Lundy arrived.
The purpose of the visit is in regards to complaint # 28-AS-20220713092003 and that the facility didn't submit a Special Incident Report (SIR) to Licensing in regards to an allegation of staff sexually assaulting client.
Interview with Administrator who confirmed that a Special Incident Report (SIR) had not been sent in.


Deficiency cited on 809 D.


Exit interview conducted and copies provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2022
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 2
Document Has Been Signed on 10/05/2022 03:07 PM - It Cannot Be Edited


Created By: Glenn Trueman On 10/05/2022 at 02:44 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: 10/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/06/2022
Section Cited
CCR
80061(b)(1)(E)

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Reporting Requirements
Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.
Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.


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The Administrator will provide an unusual incident report(SIR) to CCLD/Attn: Glenn Trueman by POC due date.

Administrator submitted Special Incident Report (SIR) at visit.
Deficiency cleared.
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 This requirement has not been met as evidenced by: The facility failed to report the Special Incident Report regarding allegation of Staff inappropriately sexual with resident in care which poses a potential health and safety risk to the clients 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:Wei Siew Ho
LICENSING EVALUATOR NAME:Glenn Trueman
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2022


LIC809 (FAS) - (06/04)
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