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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802765
Report Date: 02/07/2025
Date Signed: 02/07/2025 04:14:35 PM

Document Has Been Signed on 02/07/2025 04:14 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:
02/07/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:56 PM
MET WITH:Anna Marie Larks, Administrator TIME VISIT/
INSPECTION COMPLETED:
04:17 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) Alberto Lopez conducted a Case Management (CM) unannounced visit to obtain to and met with Staff Peter Lacsina follow up on Regional Center Simi- Annual residential review. LPA discussed the purpose of the visit. Administrator Anna Elam showed up a short time later.

LPA took tour of facility to observe corrections that had been completed in regard to Regional Center Simi- Annual residential review. LPA observed the following:

Physical Plant:
1) Front door is hard to open and close.
The facility has not repaired the front door.
2) The back door screen is torn.
The facility has not repaired screen door.
3) Boxes and other items in the back yard.
Facility has not removed the boxes (diapers) and other items from the back yard.

Food.
1) There was not enough can goods in the pantry.
Facility has purchased additional can good and fruits and vegetables.

Recreational opportunities.
1) Residents should attend community and recreational opportunities at least once per week.
Both residents stated they recently went to the movies and target.

Reporting requirements.
1) Staff explained his knowledge of reporting requirements and it met department regulations.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2025
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 3
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: 02/07/2025
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
26
27
28
29
30
31
32
(continued from 809)


Health and safety.
Appropriate medical treatment provided to residents.
1) Medical Appointments for both residents is scheduled for February 27th 2025. Administrator will send proof to LPA

Residents Rights.
1) Administrator has 2 clients that are over 60 years of age. Administrator will decided if she wants to convert to RCFE or place clients elsewhere. Administrator will operate as RCFE until she decides. Administrator will consult with regional center and provide LPA with her decision by 02/28/2025



Deficiencies cited on 809D, exit interview conducted with Administrator and copy of report and appeal rights
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2025
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/07/2025 04:14 PM - It Cannot Be Edited


Created By: Alberto Lopez On 02/07/2025 at 03:34 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: 02/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/21/2025
Section Cited
CCR
80087(a)

1
2
3
4
5
6
7
80087(a) Buildings and Grounds. The facility shall be kept clean, sanitary and in good repair at all times.

This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator will repair the front door, the back screen door, removed the boxes and other items in the back yard and send proof to LPA by POC date.
8
9
10
11
12
13
14
The front door is still difficult to open and shut as it is scarping on the bottom. The back screen door needs repair. The boxes and other items are in the back yard. Front door has two knobs and one needs to be removed.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 02/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2025


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