191221453-2-23-2026-28-AS-DKOI-DRKU8X-20260223142213

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191221453
Report Date: 02/23/2026
Date Signed: 02/23/2026 02:22:57 PM

Document Has Been Signed on 02/23/2026 02:22 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	LUNDY FAMILY CARE HOME		FACILITY NUMBER:	191221453
ADMINISTRATOR/ DIRECTOR:	LUNDY, DWYANE		FACILITY TYPE:	735
ADDRESS:	964 N SUMMIT AVE.		TELEPHONE:	(626) 794-5124
CITY:	PASADENA	STATE: CA	ZIP CODE:	91103
CAPACITY: 4		CENSUS: 3	DATE:	02/23/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:12 AM
MET WITH:	Dwayne Lundy, Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:30 PM

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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Required-1 year visit and met with the Administrator, Dwayne Lundy and the LPA explained the purpose of the visit. 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, two (2) client bedrooms, two (2) bathrooms, one (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 floor is inaccessible to clients, currently under construction which used to be a storage area. LPA requested the Administrator to send an updated floor plan/facility sketch. Client bedrooms were toured. Each bedroom has a bed, linen, dresser, light and sufficient closet space. Extra towels are stored in the bathroom #1. Extra linens are stored in cabinets in the family room. 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. LPA measured hot water temperature readings 117.3 degrees F in bathroom #1 and 117.6 degrees F in bathroom #2 which is within the required 105 - 120 degrees Fahrenheit.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/23/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026

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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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LUNDY FAMILY CARE HOME	FACILITY NUMBER: 191221453
	VISIT DATE: 02/23/2026

NARRATIVE

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There are three (3) fire extinguishers which were last serviced on 04/05/2025. Exit doors are free of any obstruction and there are no pools or large bodies of water. LPA observed a sitting space in the backyard with a shaded area.

Operational Requirements: A fire clearance is in place. Valid Liability Insurance and valid Surety bond is in place.

Staffing: A total of five (5) staff members including the Administrator provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and are associated to the facility.

Personnel Records-Training: LPA reviewed four (4) staff files including the Administrator which included Personnel Record, Health Screening, TB Clearance, Employee Rights, and Staff training. Administrator’s certificate is valid and expires on 08/30/2026. LPA observed valid HIV and TB training in the Administrator’s file. Based on record review, Administrator, Staff # 1 (S1) to Staff #3 (S3’s) file did not have a valid First Aid training. Based on record review, LPA observed Staff #2 (S2’s) file did not have Health Screening.

Client Rights-Information: Client personal rights are posted. Facility provides internet service and phone to the clients.

Food Service: The kitchen was inspected and the food preparation area and storage areas were observed to be clean and sanitary. 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 no clients with special diets residing at this facility. Pesticides and cleaning supplies are kept away from the food preparation areas.

Client Records-Incident Reports: LPA reviewed three (3) client files which included Face Sheet, Admission Agreement, IPP, Physician’s Report, Ambulatory Status, TB clearance, and Clients Personal Rights.

Health Related Services: The medications are centrally stored. LPA reviewed medication for three (3) clients. The facility uses Medication Administration Record (MAR) to document medications given. Medications are administered as prescribed by the Physician. Facility has First Aid Kit with all the required items.

Incidental Medical Services: Per Administrator, there are no clients at this home with incidental medical services nor have a restricted health condition.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/23/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LUNDY FAMILY CARE HOME	FACILITY NUMBER: 191221453
	VISIT DATE: 02/23/2026

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Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least two (2) relocation sites. Based on record review, the most recent documented emergency fire/earthquake drill was conducted on 03/01/2025.

Emergency Intervention: No manual restraints or seclusion are used with clients in care.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during today’s visit will be documented on the LIC809-D. Exit interview was 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: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/23/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/23/2026 02:22 PM - It Cannot Be Edited

Created By: Daniel Konishi On 02/23/2026 at 01:25 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: 02/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80066(a)(10)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, LPA observed Staff #2 (S2’s) file did not have Health Screening which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/09/2026
	Plan of Correction
1 2 3 4	Administrator will send a copy of Staff #2 (S2's) Health Screening to the LPA by POC due date.

Type B

Section Cited

CCR

80075(f)

Health-Related Services

(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, Administrator, Staff # 1 (S1) to Staff #3 (S3’s) file did not have a valid First Aid training in file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/09/2026
	Plan of Correction
1 2 3 4	Administrator will send Administrator, Staff #1 (S1) to Staff #3 (S3's) valid First Aid training to the LPA 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:

	Daniel Konishi
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/23/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026

LIC809 (FAS) - (06/04)

Page: 5 of 6

Document Has Been Signed on 02/23/2026 02:22 PM - It Cannot Be Edited

Created By: Daniel Konishi On 02/23/2026 at 01:25 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: 02/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	Based on record review, the most recent documented emergency fire/earthquake drill was conducted on 03/01/2025 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/09/2026
	Plan of Correction
1 2 3 4	Administrator will conduct a Emergency fire/earthquake drill and send the log to the LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

	Daniel Konishi
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/23/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026

LIC809 (FAS) - (06/04)

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