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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601507
Report Date: 07/30/2024
Date Signed: 07/30/2024 12:39:35 PM

Document Has Been Signed on 07/30/2024 12:39 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:LOST RIVER HOMEFACILITY NUMBER:
198601507
ADMINISTRATOR/
DIRECTOR:
NAVEEN REDDYFACILITY TYPE:
735
ADDRESS:21625 LOST RIVER DR.TELEPHONE:
(909) 510-9314
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY: 4CENSUS: 4DATE:
07/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Mercedita Sibal, Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection using the Compliance and Regulatory Enforcement (CARE) tool. LPA arrived unannounced and met with Staff, Mercedita Sibal. The administrator, Naveen Reddy, arrived shortly after. The facility is licensed for (4) ambulatory developmentally disabled adults, ages 18 to 59.

LPA toured the facility, reviewed files, and conducted interviews. The facility does not have any pool or bodies of water on the premises. There are 4 client bedrooms, 1 administrator's office, 2 bathrooms, dining room, family room. kitchen, and attached garage. Each client has their own bedroom with appropriate furniture and storage space. There are extra linens and hygiene supplies. Facility has an operable smoke detector in each room and are interconnected. There is a smoke and carbon monoxide combo detector located in the hallway. Knives, cleaning solutions, and disinfectants are locked. The facility measures the hot water daily and documents the temperature. The facility is operating within the fire clearance approval. Staff are continuing to follow their infection control plan and procedures while handling clients. LPA observed sufficient food supplies of 2 day perishable and a week of non-perishable items. Foods are properly stored in the refrigerator to avoid contamination.
There appears to be sufficient staffing to assist the clients. They have one overnight staff awake to supervise clients. Staff are all fingerprint cleared and associated to the facility. LPA reviewed records for 4 clients. The required documents and P&I ledgers are in their files. LPA also reviewed 3 staff files. The administrator's certificate expires on 6/2/25. The HIV & TB certificates are still valid. Staff files have the appropriate documents and CPR & First aid certificates are current. Staff do not use any manual restraints on clients. Medications are centrally stored and inaccessible to clients. LPA reviewed medications for all 4 clients and are being administered as prescribed. The facility has the updated emergency and disaster plan and conducting quarterly drills. LPA issued a technical advisory on the quarterly drills.

No deficiencies were issued today. A copy of this report was given to Administrator Reddy.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2024
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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