<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802765
Report Date: 07/18/2023
Date Signed: 07/18/2023 02:25:19 PM

Document Has Been Signed on 07/18/2023 02:25 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: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:
07/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:08 PM
MET WITH:Anna Elam - Administrator TIME COMPLETED:
02:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE tool. LPA met with Anna Larks - Elam Administrator and explained the reason for the visit.

The facility is approved for 4 Developmentally Disabled Adults, ages 18-59 and ambulatory only. This facility is a single story home located in a residential area. There are 2 client bedrooms, 2 staff bedrooms, 2 bathrooms, living room, dining room, kitchen, laundry space, and a detached garage.

LPA conducted a tour of the facility with administrator and observed the following:
Facility is in good repair inside and outside. Living room and dining room have sufficient lighting and sitting space. Kitchen was observed clean. Medication cabinet is located in the kitchen and locked. Cleaning supplies are under the kitchen's sink and kept lock. There are sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables. Thermometer was observed in the freezer at 0 degrees F. Refrigerator does not have a thermometer. Laundry area is located in the hallway. Client's bedrooms (2) were observed and have sufficient lighting, the required furniture and bedding supplies. Bathrooms (2) were observed in working condition and water temperature was tested between 108.6 - 110.4 degrees F., which is within the required 105-120 degrees F. Backyard has a shaded sitting area. Smoke/Carbon monoxide detector were observed, tested, and in working condition. Fire extinguisher was last checked on 7/15/23.

LPA reviewed files P&I money, and medication for 3 clients and 4 staff files. Last fire drill was conducted on 6/17/23. Staff #3 (S3) was missing health screening. Infection control was reviewed and per administrator was submitted to the department on 7/10/23. Emergency Disaster Plan (10/92) was observed. Administrator certificate #6013989735 exp date: 6/15/23 was submitted for renewal and it is pending.

Deficiencies were noted on LIC 809D per Title 22 Regulations.
Exit interview was conducted with administrator and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023
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 3
Document Has Been Signed on 07/18/2023 02:25 PM - It Cannot Be Edited


Created By: Mary G Flores On 07/18/2023 at 02:09 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: LARKS ADULT RESIDENTIAL FACILITY #3
FACILITY NUMBER: 197802765

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2023

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, the licensee did not comply with the section cited above in during file review S3 did not have a health screening on filewhich poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2023
Plan of Correction
1
2
3
4
Administrator will have S3 obtain a health screening and will submit copy to the department by POC due date 8/1/23.
Type B
Section Cited
CCR
85076(d)(3)
Food Service
(3) Refrigerators shall be large enough to accommodate required perishables and shall maintain a maximum temperature of 45 degrees F (7.2 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in facility's refrigerator did not have a thermometer which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2023
Plan of Correction
1
2
3
4
Administrator will provide a thermometer for refrigerator and will ensure temperature is within the recommended of less than 45 degrees F.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/18/2023 02:25 PM - It Cannot Be Edited


Created By: Mary G Flores On 07/18/2023 at 02:09 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: LARKS ADULT RESIDENTIAL FACILITY #3
FACILITY NUMBER: 197802765

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in LIC 610 (10/92) was reviewed during the visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2023
Plan of Correction
1
2
3
4
Administrator will update LIC 610 (10/92) to the current version 12/21 and will provide a copy to the deparment by POC due date 8/1/23.
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.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023


LIC809 (FAS) - (06/04)
Page: 3 of 3