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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600856
Report Date: 10/05/2023
Date Signed: 10/05/2023 05:14:00 PM

Document Has Been Signed on 10/05/2023 05:14 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
GREATER LA AC/SC, 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:
10/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:02 PM
MET WITH:Mary Anne NacuaTIME COMPLETED:
05:24 PM
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Licensing Program Analyst (LPA) Alberto Lopez conducted the required annual inspection. LPA arrived unannounced and met with DSP Leticia Romero and Lalanie Milroy and Administrator Mary Anne Nucua showed up a short time later and assisted with the inspection today. The facility is licensed for 6 residents ages 19-59. The fire clearance is approved for Six (6) non- ambulatory residents. Currently there are 4 residents at the facility.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and here are the domains that LPA inspected:

1, Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting the clients. Staff are cleaning and disinfecting each shift for high touched surface area. Facility has sufficient PPE supplies and has an Infection Control Plan.
2. Physical Plant and Environmental: The facility is a single story house and located around residential neighborhood area. The facility includes living room, dining area, kitchen, four clients bedrooms, two bathrooms, live in staff room and an attached garage with laundry area and for storage use. LPA inspected the carbon monoxide detector and is working probably. The smoke detectors are located in each room and common area, and they are working well. LPA tested the hot water temperature in two clients bathrooms and kitchen, and they were tested between 105 – 106.7 degrees F. which are within the Title 22 regulation. All the sharp knives and utensils are locked in the garage adjacent to the kitchen. All the cleaning supplies and chemicals are locked under the kitchen sink. The facility has sufficient personal hygiene products for clients to use. All clients rooms are furnished and have required beddings. All the bathrooms are clean, sanitized, and operational. The exit and passageway are safe and free of obstruction.

(Continued on (809C)

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: LARDIZABAL HOME
FACILITY NUMBER: 198600856
VISIT DATE: 10/05/2023
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3. Operational Requirements: The facility maintained a fire clearance approved by the fire department for 6 clients of which 6 may be non-ambulatory. Currently All the clients in the facility are non-ambulatory. The facility also has shaded area with table and chairs for client to utilize for outdoor activity. The last fire/disaster drill was conducted on 7/08/23.

4. Staffing: The facility has sufficient staffing, and the night supervision staff did have current CPR/first aid certification.


5. Personnel Record-Training: All the staff files are maintained in the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. The administrator (Maria Anne Nacua) certificate will be expired on 05/24/2024. The administrator did have an updated HIV and TB training certificate and the last one was completed on 04/2022. All the direct care staff received Medication Management Training. The first aid training certificates for staff is current.
6. Clients Right-Information: The facility does not have any client that requires postural support. The facility does have internet service and provides at least one access device. Let Us Know and personal rights are posted at facility.

No deficiencies observed during this visit. Due to time constraints, LPA will return another day to complete annual inspection. Copy of report and appeal rights provided to Administrator Mary Anne Nacua
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC809 (FAS) - (06/04)
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