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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602013
Report Date: 10/03/2023
Date Signed: 10/03/2023 04:58:01 PM

Document Has Been Signed on 10/03/2023 04:58 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:LUBEC HOME IIFACILITY NUMBER:
198602013
ADMINISTRATOR:AYUB WALAYATFACILITY TYPE:
734
ADDRESS:10429 TRISTAN DRTELEPHONE:
(310) 991-3245
CITY:DOWNEYSTATE: CAZIP CODE:
90241
CAPACITY: 5CENSUS: 5DATE:
10/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:54 PM
MET WITH:Ronald Yuson - Co Administrator and Smyrna Dojcinovic - LicenseeTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was screened and met by Smyrna Dojcinoviv, Licensee and Ronaldo Yuson, Co-Administrator and explained the purpose of the visit. The facility is licensed to care for five (5) bedridden adults. All clients residing at this facility receive case management services provided by South Central Los Angeles Regional Center.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The staff are wearing masks throughout their shift and disposable gloves are used to clean and disinfect the high touched surfaces in the common areas. The facility has submitted a COVID-19 Mitigation Plan. Facility has COVID-19 signage posted throughout the facility. Bathrooms have hand washing signs, soap and paper towels. Staff are adhering to infection control requirements. The Administrator is responsible for communicating with emergency personnel in the facility.

Physical Plant/Environment Safety: The facility is a single storey home located in a residential neighborhood, contains a total of (5) bedrooms, (2) bathrooms, a living room, kitchen, dining area, backyard, and detached garage/storage. Currently, there are five (5) clients living in the facility. The interior and exterior physical plant was inspected. Licensee is not operating beyond the conditions and limitations specified on the license, including the capacity. All clients are protected against hazards. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, chair and sufficient closet space. Client bedrooms have the required furnishings. Bathrooms have non-skid materials and contained hygiene supplies including liquid soap, paper towels, and toilet paper. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and has a shaded area and sitting area. Detached garage was inspected and stores additional PPEs and other medical equipment. Kitchen knives, sharps objects, cleaning supplies and toxic substances are locked in the kitchen drawer and inaccessible to clients. There are (2) fire extinguishers observed to be fully charged and was last serviced on 1/30/2023. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Hot water supply measured 116.6 deg F in bathroom #1, and 115.3 in bathroom #2.

Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. An annual fire inspection is conducted by USA Fire & Safety Inc., last inspection held on 3/12/2023. A fire clearance for (5) clients is in place. Liability Insurance policy in the amount of $1,000,000.00 each occurrence and #3,000,000.00 in the total annual aggregate is valid and will expire on 2/17/2024. Surety Bond is in effect and in force with bond amount of $5000. The insurance will expire on 5/20/2024. Last Fire Drill was conducted on 09/12/2023. Emergency and Disaster Plan drill was last conducted on 9/18/2023.

*****REPORT CONTINUED ON LIC809-C*****

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2023
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: LUBEC HOME II
FACILITY NUMBER: 198602013
VISIT DATE: 10/03/2023
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Personnel Records/Staff Training: A total of ten (10) staff members including the (2) Administrators and the Licensee provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Sufficient staff as necessary to ensure provision of care and supervision to meet client needs were observed. Reviewed files for three (3) staff. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator certificate is valid and expiring on 09/7/2023 and Co-Administrator's certificate has expired on 6/21/2023, but had submitted renewal to DSS on 6/17/2023. Administrators have valid HIV/AIDS training proof at the time of visit. There is an Administrator on the premises a sufficient number of hours necessary to adequately administer the facility in compliance with applicable law and regulation.

Client Records-Incident Reports: LPA reviewed Client files for C1 through C3. Client files are maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Behavioral Reports, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.

Client Rights-Information: Client personal rights are posted. Per Administrator, facility provides internet services to all clients and have access to the facility phone. However, all clients are non verbal. Administrator stated that none of the clients have a personal cell phone and own tablet. LPA attempted to conduct client interviews but all clients are non verbal. The lift system was tested in each bedroom and all were operating properly during the visit.

Food Service: There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator (clean and well maintained). All the clients residing in the facility require special/restricted diets and gastronomy feeding. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: The medications are centrally stored in a double-locked medicine cart and in their original containers. Controlled substances are stored in a separate locked container inside the cart. Medications were reviewed for C1-C5 to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician and are bubbled packed. All medications are labeled and maintained in compliance with label instructions and State and Federal law.

Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan.

Exit interview and a copy of this report was provided to the Co-Administrator, Ronald Yuson.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
LIC809 (FAS) - (06/04)
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