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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600205
Report Date: 04/23/2024
Date Signed: 04/23/2024 01:17:36 PM

Document Has Been Signed on 04/23/2024 01:17 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/
DIRECTOR:		PORTER, LEE FRANCESFACILITY TYPE:
735
ADDRESS:556 PRIOR STREETTELEPHONE:
(626) 968-4622
CITY:VALINDASTATE: CAZIP CODE:
91744
CAPACITY: 4CENSUS: 4DATE:
04/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Administrator Angela Porter TIME VISIT/
INSPECTION COMPLETED:
01:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jose Villalobos conducted the unannounced Annual Inspection visit using the Compliance And Regulatory Enforcement (CARE) Tool. LPA met with Administrator Angela Porter and the purpose of the visit was discussed.

Infection Control: LPA observed the facility has sufficient PPE supplies. Infection Control Plan is in place. The plan was collected and reviewed.

Physical Plant and Environmental Safety: The facility is licensed to serve (4) Ambulatory clients of ages between 18-59 of which one (1) may be non-ambulatory. There are currently four (4) clients who are placed by the San Gabriel Pomona Regional Center. Facility is located in a residential area and consist of a living room, attached garage/laundry area, dining area, kitchen, activity room, 4 client bedrooms and 1 1/2 bathrooms. The facility was inspected during the physical plant tour. No passageways or paths were obstructed.

Operational Requirements: Facility is operating within its approved clearance.

Staffing: The facility has a sufficient staffing in the facility. Facility is present during the Nightshift.

Personnel Records-Training: Personal records centrally stored. LPA inspected five (5) staff files. All staff are background check cleared and associated with the facility. All the staff files have the required Title 22 documents. The administrators certificate is currently active.

Client's Right - Information: No client in the facility required any postural support at the present time. Required postings observed.

Continued on LIC 809-C
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/23/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 198600205
VISIT DATE: 04/23/2024
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Food Service: Supply of Non perishables and perishables was observed. Food supply was adequately stored. Pesticides and other toxic substances were not stored with the food supply. Kitchen area was clean.

Client Records/Incident Reports: Client files are centrally stored. LPA reviewed four (4) client files. Client files are up to date and have required documents.

Health Related Services: Medication is centrally stored and locked making them inaccessible to clients in care. LPA reviewed four (4) Client Medications. (1) Clients uses powdered inhalation devices. Staff training on assistance with those devices not observed.

Incidental Medical Services: No restricted health condition plans in place. There are no clients in care with prohibited health conditions. First Aid kid observed and available when needed.

Disaster preparedness: The facility was not able to provide LPA with the Emergency Disaster Plan. Facility has client information readily available in case of emergencies.

Emergency Intervention: The facility are not using any restraints in the facility.

Per Title 22 Regulations, deficiencies are being cited on todays visit. Please see attached 809-D page(s)

Exit Interview conducted. Appeal rights and a copy of the report were provided and discussed.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/23/2024 01:17 PM - It Cannot Be Edited


Created By: Jose Villalobos On 04/23/2024 at 01:03 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: LANESBORO RESIDENTIAL CARE
FACILITY NUMBER: 198600205

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)(1)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (1) In adult CCFs, facility staff who receive training may assist clients with metered-dose inhalers, and dry powder inhalers if the following requirements are met:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above (1) client in care receives assistance with dry powder inhalers but staff do not have training for it on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2024
Plan of Correction
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Facility to provide LPA the date when training is scheduled by POC due date. Facility to then provide completion of training for review once completed.
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as Facility was not able to provide LPA the emergency disaster plan during the visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2024
Plan of Correction
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Facility to complete and submit Emergency Disaster Plan (LIC 610D) by POC due 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.
SUPERVISOR'S NAME:Fernando Fierros
LICENSING EVALUATOR NAME:Jose Villalobos
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024


LIC809 (FAS) - (06/04)
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