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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600856
Report Date: 10/10/2023
Date Signed: 10/10/2023 04:14:55 PM

Document Has Been Signed on 10/10/2023 04:14 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:
10/10/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:02 PM
MET WITH:Mary Anne NacuaTIME COMPLETED:
04:23 PM
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Licensing Program Analyst (LPA) Alberto Lopez made subsequent unannounced visit to continue annual inspection. LPA met with Mary Anne Nacua and discussed purpose of the visit.
LPA observed the following:

7. Client Records/Incident Reports: Four (4) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, nutritional assessments, medication records, and P & I money were reviewed. Records for P&I money need to be updated to reflect actual expenditures, receipts, and balance. All 4 clients ledgers are not accurate.

8. Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

9. Health Related Services: Clients are assisted with self-administration of prescription medications. Four (4) centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked cabinet and not accessible to clients in care. Medications are given according to Physician directions.

10. Incident Medical and Dental: All clients have a Needs and Services Plan, and COVID-19 vaccination cards on file. Staff training was on file.

11. Disaster Preparedness, and Emergency Intervention: A posted Emergency Disaster Plan LIC 610D containing emergency evacuation information was observed and updated An emergency drill was last documented on 07/02/2023.

12. Emergency Intervention: No manual restraints or seclusion are used with clients in care.


Per California Code of Regulations, Title 22, and California Health and Safety Code, No deficiencies observed during the visit are documented. Exit interview held and a copy of the report along with appeal rights were provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2023
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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