198601880-8-26-2022-28-AS-LMOA-CHNPVW-20220826113948

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601880
Report Date: 08/26/2022
Date Signed: 08/26/2022 11:39:56 AM

Document Has Been Signed on 08/26/2022 11:39 AM - 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:	LUBEC HOME		FACILITY NUMBER:	198601880
ADMINISTRATOR:	RONALD YUSON		FACILITY TYPE:	734
ADDRESS:	9294 LUBEC STREET		TELEPHONE:	(562) 923-0900
CITY:	DOWNEY	STATE: CA	ZIP CODE:	90240
CAPACITY: 5		CENSUS: 3	DATE:	08/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Ayub Walayat - Co-Administrator		TIME COMPLETED:	11:45 AM

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) Luis Mora conducted an unannounced annual visit at the facility with focus on the infection control domain, medication and food review. LPA Mora met with Co-Administrator Ayub Walayat and explained the reason for the visit. The facility is an Adult Residential Facility for Persons with Special Health Care Needs (ARFPSHN) and it is licensed to serve 5 bedridden adults. Facility currently has 3 bedridden clients serviced by the South Central Los Angeles Regional Center. The facility is in a residential area and it is a one story family home. A tour of the single-story facility included the following: 5 client bedrooms, 2 bathrooms, kitchen, living room, dining room, patio, front yard, backyard, and am attached garage. LPA Mora conducted the tour with Ayub Walayat and observed the following: sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were observed in the kitchen. Sharps were observed locked in a kitchen cabinet. Chemical and cleaning solutions are kept locked under the kitchen sink. The First Aid kit is kept locked in the living room and it is fully stocked with all required items including a current manual. Clean towels and extra clean linen were observed in the hallway cabinet. Dining and living room have sufficient lighting and sitting area. Medications are kept locked in a cabinet near the kitchen. Client files and staff files are kept in the garage. All bedrooms have all required furniture, lighting, and bedding. All bathrooms were observed with shower mats. The water temperature was tested in both bathrooms and measured at 112.4 degrees F and 114 degrees F, which is within the required 105-120 degrees F. A fire extinguisher was observed in the kitchen, living room, and garage and are fully charged. Smoke detectors and carbon monoxides were observed throughout the facility and were operable during the visit. The facility has sprinkler system in place. The emergency generator was last tested on 08/23/22, it is tested every 14 days. The front yard and backyard are clean. There is a shaded area with seating in the patio. No bodies of water were observed at the facility. Passageways and exits are free of obstruction. (CONTINUED TO LIC 809C)

SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LUBEC HOME	FACILITY NUMBER: 198601880
	VISIT DATE: 08/26/2022

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LPA reviewed medication for all 3 clients and observed that medications are documented properly and given as prescribed. LPA reviewed files for all 3 clients and 3 staff. No issues were found with the files. LPA observed administrator certificate for Ronald S Yuson – 6030693735 with an expiration date of 06/21/2023 and administrator certificate for Ayub J Walayat – 6032065735 with an expiration date of 09/07/2022.

Facility has 30 days supplies of Personal Protective Equipment (PPE) in the garage and has placed PPE supplies outside every bedroom. Facility is following COVID-19 recommendations regarding screening visitors, staff, and clients. Covid-19 prevention signs are posted throughout the facility and hand-washing signs were observed in the bathrooms. Sufficient hand soap, hand sanitizer, and paper towels were observed.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.

SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

LIC809 (FAS) - (06/04)

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