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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600205
Report Date: 11/17/2021
Date Signed: 11/29/2021 11:40:46 AM

Document Has Been Signed on 11/29/2021 11:40 AM - 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:LANESBORO RESIDENTIAL CAREFACILITY NUMBER:
198600205
ADMINISTRATOR:PORTER, LEE FRANCESFACILITY TYPE:
735
ADDRESS:556 PRIOR STREETTELEPHONE:
(626) 968-4622
CITY:VALINDASTATE: CAZIP CODE:
91744
CAPACITY: 4CENSUS: 4DATE:
11/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Angela PorterTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Christine Wong a conducted an annual required visit. LPA met with staff Cesario Donato and explained the reason for the visit. Shortly after, the administrator Angela Porter arrived and assisted with the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures and observed food supply. Facility has submitted a mitigation plan and was approved on 04/14/2021.

The facility is located in a residential neighborhood. The facility consists of kitchen, living room, dining area, four clients bedrooms, two bathrooms, game room and attached garage. All four (4) clients bedrooms were toured. Each room has a single bed, dresser, chair, required linen and furniture and sufficient lighting and closet space. All two (2) bathrooms were toured. Bathrooms are clean and maintained in good condition. The hot water was tested between 109.3 and 112.3 degrees F. which is within Title 22 regulation. For the food supply, the refrigerator in the kitchen and pantry has sufficient two days perishable and seven days non-perishable food. All the appliances in the kitchen are working properly. The sharp utensils and knives are locked in the cabinet in the living room. The common area such as living room and dining area are clean and have the required furniture. The front and back yard are well maintained. The back yard has a shaded area and sitting area. The cleaning products are locked in the cabinet in the garage which is inaccessible to clients. The medications are centrally stored and locked in a cabinet in the living room. Each bedroom and common area has a smoke detector and they are operated well. The carbon monoxide detectors are located at the living room and its working properly.

Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, and social distancing. The facility is disinfected every shift (3 times a day) and the bathroom have sufficient soap, paper towels, and signs. PPE supplies are also sufficient for 30 days.

Exit Interview conducted. A copy of the report was provided to the administrator Angela Porter
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2021
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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