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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602013
Report Date: 12/08/2021
Date Signed: 12/08/2021 02:06:23 PM

Document Has Been Signed on 12/08/2021 02:06 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:LUBEC HOME IIFACILITY NUMBER:
198602013
ADMINISTRATOR:SMYRNA DOJCINOVICFACILITY TYPE:
734
ADDRESS:10429 TRISTAN DRTELEPHONE:
(310) 991-3245
CITY:DOWNEYSTATE: CAZIP CODE:
90241
CAPACITY: 5CENSUS: 3DATE:
12/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Ayub Walayat (Administrator)TIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Kruz Long conducted a site visit for the annual inspection. Upon arriving at the facility LPA met with Ayub Walayat (Administrator) and explained the purpose of the visit. The facility is licensed to serve five (5) bedridden adults.

The facility is located in a residential area. A tour of the single-story facility includes: Living room, dining area, kitchen, 5 bedrooms, 2 bathrooms and a detached garage/storage.

During today’s visit, LPA observed the following: Licensee is not operating beyond the conditions and limitations specified on the license, including the capacity. All clients are protected against hazards. All outdoor and indoor passageways are free of obstruction. There are no pools or large bodies of water on the premises. Disinfectants, cleaning solutions, poisons are inaccessible to clients. A comfortable temperature for clients is maintained. All client bedrooms have the required furnishings. Smoke and Carbon Monoxide detectors are operable. Fire extinguishers are fully charged. Hot water temperature measured at 117.8 degree F in bathroom #1. All toilets, hand washing and bathing facilities is safe, sanitary and in operating condition. Sufficient staff as necessary to ensure provision of care and supervision to meet client needs were observed. Staff responsible for direct care and supervision have current first aid and criminal record clearance. LPA was allowed to enter the facility to conduct the inspection. The administrator is on the premises a sufficient number of hours necessary to adequately administer the facility in compliance with applicable law and regulation. All lift systems is operable. All medications are labeled and maintained in compliance with label instructions and State and Federal law. Medications are safe and locked. All 3 clients require gastronomy feeding and medication administration.

No deficiencies were observed during today's visit.

An exit interview was conducted with Ayub Walayat and a copy of this report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2021
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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