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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600856
Report Date: 06/10/2022
Date Signed: 06/10/2022 12:02:51 PM

Document Has Been Signed on 06/10/2022 12:02 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:LARDIZABAL HOMEFACILITY NUMBER:
198600856
ADMINISTRATOR:MARY ANNE NACUAFACILITY TYPE:
735
ADDRESS:212 LONE HILL AVETELEPHONE:
(626) 857-1071
CITY:GLENDORASTATE: CAZIP CODE:
91741
CAPACITY: 6CENSUS: 6DATE:
06/10/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Mary Ann Nacua- AdministratorTIME COMPLETED:
12:05 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 Analysts (LPA) Valeria Maldonado conducted a Case Management visit in order to review the facilities compliance with Title 22 and the Stipulation and Waiver; and Order, dated June 7, 2017. LPA was greeted by staff Lalani Milroy and was greeted shortly after by administrator Mary Ann Nacua. Today's Case Management visit was conducted with the administrator.

During today's visit, LPA toured the physical plant with administrator Mary Ann and requested copies of the staff and resident rosters. During the tour, LPA observed that the physical plant was clean and in good repair. Disinfectants, cleaning solutions, poisons, and other items which could pose a danger are inaccessible to residents. Fire extinguisher mounted to the kitchen wall and in the hallways are fully charged. Telephone system is an operable land line located in the living room. First aid kit is fully stocked, includes the first aid manual, and is locked in the kitchen cabinet. Medications are also locked in the kitchen cabinet and inaccessible to residents. Sufficient food supplies were observed. All walkways and pathways are free of obstruction. Attached garage is used for storing of extra food, linens, additional cleaning supplies and laundry is done there. The home has (4) rooms, (1) of which is used for the live-in staff. All resident rooms are shared, have the required furniture, linens, and have adequate lighting. Hygiene items of general use such as soap and toilet paper are available. Water temperature measured at 107.8*F in bathroom#1 and 111.4*F in bathroom# 2. Smoke detectors/carbon monoxide detector are interconnected and operable. All bathrooms contain operable toilets, hand wash basins, and showers. There is an outdoor shaded area. No deficiencies were observed during today's visit.

An exit interview was conducted with administrator Mary Ann Nacua and a copy of the report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2022
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 1