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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600856
Report Date: 10/28/2022
Date Signed: 10/28/2022 03:51:01 PM

Document Has Been Signed on 10/28/2022 03:51 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: 4DATE:
10/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Mary Anne Nacua- AdministratorTIME COMPLETED:
04:00 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) V. Maldonado made an unannounced visit at the facility for the purpose of conducting the required Annual Inspection, using the Infection Control Evaluation Tool. LPA Maldonado met with Direct Support Staff (DSP) Lalanie Milroy and explained the purpose of the visit. Administrator Mary Anne Nacua arrived shortly after to assist with the visit. The facility is licensed to serve (6) non-ambulatory clients, ages 18-59- developmentally disabled only.

The facility is a 1 story home located in a residential area. The home consists of 3 client bedrooms, 1 staff bedroom, 2 bathrooms, a kitchen, a dining room, a living room, an attached garage, and a shaded patio in the backyard. LPA conducted a physical tour with DSP Lalanie and observed the following: passageways are free of obstructions and hazards. All client bedrooms have the required bedding, furniture, closet, and additional storage space. Bed linens were observed to be clean and in good repair. Additional linens were observed in a hallway closet and in the garage. The bathrooms consisted of a toilet, wash basin, and shower- all operating and in good repair. The water in the bathrooms was tested and measured at 118.8*F in bathroom# 1 and 120*F in bathroom# 2. LPA observed sufficient supply of 2-day perishables and 7-day non-perishable foods in the facility. All sharps and cleaning supplies/toxins were observed to be locked in a cabinet under the kitchen sink, and inaccessible to clients in care. There was (1) fire extinguisher in the kitchen and (1) in the hallway, both observed to have recent inspections and be fully charged. The first aid kit was observed to have the required items with a current First Aid Manual. The washer and dryer were observed in the garage to be in good repair and operating at the time of the visit. The smoke and carbon monoxide detectors were observed throughout the facility and tested during the visit. They are interconnected and operational upon testing.

COVID-19 signage was observed throughout the facility to promote hand washing, cough/sneeze etiquette, use of proper PPE, and social distancing. A 30 day supplies of PPE was observed in the garage and some throughout the facility, readily available for clients in care. (Report Continued on LIC809-C...)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2022
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 2
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: LARDIZABAL HOME
FACILITY NUMBER: 198600856
VISIT DATE: 10/28/2022
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
(3) staff files were reviewed for Criminal Background Clearances, Health Screenings, and required training certification. (4) of (4) client files were reviewed for updated Emergency Contact Information and Health Screenings. Medication Administration Records (MARs) and centrally stored medications were reviewed. Medications are centrally stored in a locked cabinet in the kitchen and are inaccessible to clients in care. Medications are documented properly and given as prescribed.

Per California Code of Regulations, Title 22 and Health & Safety Codes, no deficiencies were observed during today's visit.

An exit interview was conducted with Administrator Mary Anne Nacua and copy of the report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2