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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600205
Report Date: 06/15/2023
Date Signed: 06/15/2023 02:18:21 PM

Document Has Been Signed on 06/15/2023 02:18 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
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: 3DATE:
06/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Angela Porter (Administrator)TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Kruz Long conducted a site visit for the annual inspection. Upon arriving, LPA knocked on the front door and no one was available to answer. LPA called Angela Porter (Administrator) who arrived at the facility a short time later. LPA explained the purpose of the visit. The facility is licensed for three (3) ambulatory and one (1) non-ambulatory developmentally disabled clients, ages 18-59.

The facility is located in a residential area. A tour of the single-story facility includes: Living room, attached garage/laundry area, dining area, kitchen, activity room, 4 client bedrooms and 1 1/2 bathrooms.

LPA utilized the Compliance and Regulatory Enforcement (CARE) Tools which contain the following domains: Infection Control, Physical Plant & Environment Safety, Operational Requirements, Staffing, Personnel Reports-Training, Client Rights - Information, Client Records-Incident Report, Food Services, Health Related Services, Incidental Medical Services, Disaster Preparedness, Emergency Intervention.

During today’s visit, LPA observed the following: Licensee has ensured that infection control practices are maintained. The facility is clean, safe, sanitary and in good repair for the safety and well-being of clients, employees and visitors. Facility has secured and maintained a fire clearance approved by the city or county fire department. Facility personnel is competent to provide the services necessary to meet individual client needs and is employed in numbers necessary to meet such needs. Staff responsible for providing direct care and supervision have received training in first aid from persons qualified by agencies including but not limited to the American Red Cross. Internet service is provided with at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with video conferencing technology, including microphone and camera functions, and is dedicated for client use. The licensee completed an individual written admission agreement with each client and the client's authorized representative, if any. All kitchen, food preparation, and storage areas are kept clean, free of litter and rubbish, and measures is taken to keep all such areas free of rodents, and other vermin. The licensee has ensured that each client receives first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services. Facility have an emergency and disaster plan. Hot water temperature measured at 108.6 degree F in the full bathroom.

No deficiencies were observed during today's visit.
An exit interview was conducted and a copy of this report was provided to Angela Porter (Administrator).
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2023
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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