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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607967
Report Date: 10/21/2021
Date Signed: 11/10/2021 10:14:56 AM

Document Has Been Signed on 11/10/2021 10:14 AM - 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:LANNY'S HOMEFACILITY NUMBER:
197607967
ADMINISTRATOR:LANNY WONOPRABOWOFACILITY TYPE:
735
ADDRESS:10445 ARNWOOD RDTELEPHONE:
(818) 899-7374
CITY:LAKEVIEW TERRACESTATE: CAZIP CODE:
91342
CAPACITY: 4CENSUS: DATE:
10/21/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:44 AM
MET WITH:Murnaningsih “Ester” Cordova TIME COMPLETED:
01:50 PM
NARRATIVE
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---- This is an amended report to remove confidential information ----
At 9:44 AM on 10/21/2021, Licensing Program Analyst (LPA) Nicholas Reed arrived to Lanny’s Home (#197607967) for an unannounced complaint investigation. LPA rang the doorbell twice and staff S2 answered the door. S2 screened LPA for COVID symptoms, asking, “Do you have a fever, cough, or any other symptoms?” LPA replied, “No”. S2 asked LPA Reed to put on a mask before entering the facility. S2 also took LPA’s temperature of 97.8 degrees Fahrenheit and prompted LPA to fill out the Visitor’s Log.

At 9:55 AM, LPA toured the facility independently. Beginning outside, LPA saw and photographed a closed but unlocked gate around a pool. A pink lock hung from the gate latch and was not locked. LPA checked both exit gates of the facility. The gate closest to the pool was closed and unlocked. LPA walked down the ramp leading down to the other gate. LPA tried to open the gate but was unable to do so. The gate was locked. LPA went inside to call S2 who was supervising clients. LPA requested S2 unlock the gate at the end of the ramp. LPA told S2 that the gate must remain unlocked in case of an emergency.

At approximately 10:04 AM, LPA toured the inside of the facility with S2. LPA observed that staff room door was ajar and unlocked. LPA entered staff room and observed no medication or items endangering clients’ safety. LPA requested S2 and S1 lock the staff room door, and they closed and locked it promptly. LPA reminded staff their door must remain closed and locked. LPA toured resident rooms and bathrooms. LPA observed clean beds with pillows, linens, and client photos hanging above their beds. LPA observed bathroom stocked with soap, paper towels, and a trash can with a tight fitting lid and foot pedal.

When LPA and S2 finished tour, LPA saw two additional staff, S3 and S4.LPA met with S4. LPA requested to see the Emergency Exit sketch. S4 called Administrator to find the sketch. Administrator stated that the facility does not have a sketch.

Exit interview conducted with S4. Final report and appeal rights emailed.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2021
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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Document Has Been Signed on 11/10/2021 10:15 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 11/05/2021 03:48 PM


Created By: Nicholas Reed On 10/21/2021 at 12:26 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LANNY'S HOME
FACILITY NUMBER: 197607967

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/21/2021
Section Cited
CCR
80087(e)

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This is an amended report to remove confidential information ----
80087(e) Buildings and Grounds
All licensees serving clients who have physical handicaps or developmental disabilities shall ensure the inaccessibility of pools.This requirement is not met as evidenced by:
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Staff locked the pink lock. Deficiency corrected immediately. No POC issued.
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Based on LPA's observation, LPA saw and photographed a closed but unlocked gate around a pool. A pink lock hung from the gate latch and was not locked. Licensee did not ensure the pool gate was locked. This poses an immediate health and safety risk to the residents in care.
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Type B
10/21/2021
Section Cited
HSC80072(a)(7)

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80072(a)(7) Personal Rights
Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:
Not to be locked in any room, building, or facility premises by day or night.
This requirement is not met as evidenced by:
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Staff S2 immediately unlocked the gate. Defiency was corrected. No POC issued.
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LPA walked down the ramp leading down to the other gate. LPA tried to open the gate but was unable to do so. The gate was locked. Based on LPA's observations, this poses a potential risk to the health, safety or personal rights of residents 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:Cassandra Harris
LICENSING EVALUATOR NAME:Nicholas Reed
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2021


LIC809 (FAS) - (06/04)
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