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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602013
Report Date: 11/08/2024
Date Signed: 11/08/2024 12:09:38 PM

Document Has Been Signed on 11/08/2024 12:09 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/
DIRECTOR:
AYUB WALAYATFACILITY TYPE:
734
ADDRESS:10429 TRISTAN DRTELEPHONE:
(310) 991-3245
CITY:DOWNEYSTATE: CAZIP CODE:
90241
CAPACITY: 5CENSUS: 4DATE:
11/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:09 AM
MET WITH:Lydia Caranto - RNTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced Case Management Visit to follow up on a Death Report faxed to the Department on 10/31/24. LPA met with Lydia Caranto and Ayub Walayat and explained the reason for the visit.

Per Conversation with Administrator Ayub Walayat, whenever C1 had UTI or Pneumonia their heart rate increased, C1 had gone to the doctor in the morning of 10/28/24 to get clearance for a surgery, the doctor prescribed medication for pneumonia and later that afternoon, back at facility, C1 looked very lethargic and weak, staff called the doctor and were instructed to take C1 to the ER. C1 passed the following morning 10/29/24 in the hospital. C1 has had a history of UTI and Pneumonia and I have submitted SIR's for his multiple doctor visits and hospitalization's due to health conditions.

During today's visit, LPA received the following copies from C1’s file : FACE Sheet, Death Report, Appraisal Needs & Services Plan, Physician's Report, and Medication Administration Record (MAR) for August - October 2024.

LPA toured C1's bedroom. No concerns, obstructions, or anything out of the ordinary was witnessed during the visit. LPA has also requested facility to provide Licensing with C1's Death Certificate upon receipt.

No deficiencies observed during today's visit. Exit interview held and a copy of the report was provided.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2024
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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