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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802765
Report Date: 07/08/2025
Date Signed: 07/11/2025 02:36:26 PM

Document Has Been Signed on 07/11/2025 02:36 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: 2DATE:
07/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:13 PM
MET WITH:Anna Marie Larks, Administrator TIME VISIT/
INSPECTION COMPLETED:
04:59 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted unannounced visit to conduct the annual inspection and met with Staff Peter Lacsina. LPA discussed the purpose of the visit.

The facility is approved for 4 Developmentally Disabled Adults, ages 18-59 and ambulatory only. Currently there are 2 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, a 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:


The facility is in good repair inside and outside. The living room and dining room have sufficient lighting and sitting space. The kitchen was observed clean. The medication cabinet is in the kitchen and locked. Cleaning supplies are under the kitchen's sink and kept locked. 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 42.6 degrees which is within range. The 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 127.5 – 128.8 degrees F., which is not within the required 105-120 degrees F. Backyard has a shaded sitting area. Smoke/Carbon monoxide detectors were observed, tested, and in working condition.

(continued on 809C)

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2025
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 5
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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Document Has Been Signed on 07/11/2025 02:36 PM - It Cannot Be Edited


Created By: Alberto Lopez On 07/08/2025 at 04:19 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: 07/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Water temperature measured 127.5- 128.8 degrees F which is not within range of 105.0 -120.0 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2025
Plan of Correction
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Administrator will adjust water temperature and keep log for 3 days and fax to LPA as proof of correction.
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.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Alberto Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/11/2025 02:36 PM - It Cannot Be Edited


Created By: Alberto Lopez On 07/08/2025 at 04:19 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: 07/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. There are two large mirrors, several large chairs and other debris in the yard behind the garage which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2025
Plan of Correction
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Administrator will discard the mirrors, chairs and other debris and fax photo as proof of correction to LPA.
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. One window screen has a hole which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2025
Plan of Correction
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Administrator will repair or replace the window screen and fax photo as proof of correction to LPA by POC 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.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Alberto Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
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: 07/08/2025
NARRATIVE
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(continued from 809)

The fire extinguisher was last checked on 7/16/24. There are large mirrors, old chairs and other debris in the back yard behind the garage that needs to be discarded and one window screen has a hole and needs repair or replacement.

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 two (2) staff members provide care and supervision to the clients.

5. Personnel Records/Staff Training: Administrator’s certificate expired 06/15/2025, renewal was submitted and certificate pending. 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: Two (2) 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. and LIC602 for Residential Care Facility for the Elderly (RCFE).

8. Food Service: The kitchen was inspected and has a 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 the administration of prescription and non-prescription medications. two (2) centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked cabinet, not accessible to clients in care. Medications are given according to Physician orders.

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.

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, deficiencies observed during the visit are documented on the LIC809D. Exit interview was held and a copy of the report along with appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
LIC809 (FAS) - (06/04)
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