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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802765
Report Date: 07/29/2022
Date Signed: 07/29/2022 03:48:20 PM

Document Has Been Signed on 07/29/2022 03:48 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:LARKS ADULT RESIDENTIAL FACILITY #3FACILITY NUMBER:
197802765
ADMINISTRATOR:LARKS, ANNA MARIEFACILITY TYPE:
735
ADDRESS:3045 FRONT ST.TELEPHONE:
(626) 281-3548
CITY:ALHAMBRASTATE: CAZIP CODE:
91803
CAPACITY: 4CENSUS: 3DATE:
07/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Tuesday Sison, CaregiverTIME COMPLETED:
04:00 PM
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Licensing Program Analysts (LPAs) Cynthia Chan and Ya-Ting Yang conducted an annual inspection with the focus of the Infection Control Practice domain. LPAs met with Staff, Tuesday Sison, who allowed entry to the facility. The purpose of the visit was explained. The facility is approved for 4 Developmentally Disabled Adults, ages 18-59 and ambulatory only. There are current 3 ambulatory clients residing at the home.

LPAs toured the facility with the staff and observed/inspected the following:
  • This facility is a single story home located in a residential area. There are 4 bedrooms, 2 bathrooms, living room, dining room, kitchen, laundry space, and a detached garage. There are no obstructions to the passageways or bodies of water at the facility.
  • There are 3 bedrooms designated for clients and 1 for live-in staff. Client rooms are equipped with the required furnishings.
  • The backyard has two shaded area with tables and chairs for clients use.
  • Covid-19 signage are posted at the facility and proper handwashing posters are present in both bathrooms. Staff screened and took the temperature of LPAs upon arrival.
  • Both staff on duty wore face masks.
  • Cleaning solutions are stored and locked under the kitchen sink.
  • Knives and medications are locked in a kitchen cabinet. Medications were reviewed for all 3 clients and did not observe any discrepancies.
  • Facility has 30 days of PPE supplies.
  • Sufficient food supply of 2-day perishable and 7-day nonperishable were observed.
  • The fire extinguisher was last inspected on 6/17/22.
  • Hot water temperature was measured within the required range of 105-120 degree Fahrenheit.

No deficiencies were issued during the visit today. Exit interview was conducted and a copy of this report was given to the staff.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2022
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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