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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802765
Report Date: 06/04/2024
Date Signed: 06/04/2024 05:03:24 PM

Document Has Been Signed on 06/04/2024 05:03 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/
DIRECTOR:		LARKS, ANNA MARIEFACILITY TYPE:
735
ADDRESS:3045 FRONT ST.TELEPHONE:
(626) 281-3548
CITY:ALHAMBRASTATE: CAZIP CODE:
91803
CAPACITY: 4CENSUS: 3DATE:
06/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:36 PM
MET WITH:Anna Marie Larks-ElamTIME VISIT/
INSPECTION COMPLETED:
05:14 PM
NARRATIVE
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The facility is approved for 4 Developmentally Disabled Adults, ages 18-59 and ambulatory only. Currently there are 3 clients in care. 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. The following was observed:

1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. Facility is disinfecting throughout the day.

2. Physical Plant/Environment Safety:


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 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 have a thermometer and showed 39.7 degrees which is within range. Laundry area is 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 119.8 – 120.0 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.

3. Operational Requirements: The Program Design was reviewed. Fire clearance was approved by LA County Fire Department for three (4) ambulatory clients. Care and supervision to meet the clients’ needs was observed.


4) Staffing: A total of (4) staff members provide care and supervision to the clients.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2024
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 06/04/2024 05:03 PM - It Cannot Be Edited


Created By: Alberto Lopez On 06/04/2024 at 04:36 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: 06/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85068.4(e)
Acceptance and Retention Limitations
(e) The licensee shall ensure that the medical assessment for each client 60 years of age or older is updated at least annually and in accordance with the regulations addressing medical assessments in Residential Care Facilities for the Elderly (RCFE) [California Code of Regulations, Title 22, Sections 87458(b) and (c)].

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above all 3 clients are over 60 years and do not have updated LIC602 for RCFE which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/12/2024
Plan of Correction
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Administrator will obtain LIC602 for RCFE for all 3 clients and send copies to LPA by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2024


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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: LARKS ADULT RESIDENTIAL FACILITY #3
FACILITY NUMBER: 197802765
VISIT DATE: 06/04/2024
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5. Personnel Records/Staff Training: Administrator’s certificate 06/15/2025. Staff files were reviewed for criminal background clearance and training. Personnel records have health/TB screenings and 1st Aid/CPR training.

6. Client Rights/Information: Personal rights are posted near the entrance.

7. Client Records/Incident Reports: Six (3) client files were reviewed containing admission agreements, Current IPP, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent. All 3 clients are missing LIC602 for RCFE.

8. Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

9. Health Related Services: Clients are assisted with administration of prescription and non-prescription medications. Six (3) centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked not accessible to clients in care. Medications are given according to Physician orders. PRN authorization letters are not kept in files.

10. Incident Medical and Dental: All clients have a Needs and Services Plan, and COVID-19 vaccination cards on file.

11. Disaster Preparedness, and Emergency Intervention: A posted Emergency Disaster Plan LIC 610D containing emergency evacuation information was observed but needs to be updated.


12. 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, deficiency observed during the visit are documented on the LIC809D. Technical Advisories provided. Exit interview held and a copy of the report along with appeal rights were provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024
LIC809 (FAS) - (06/04)
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