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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602875
Report Date: 04/22/2025
Date Signed: 04/22/2025 10:59:08 AM

Document Has Been Signed on 04/22/2025 10:59 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CASA BARBARAFACILITY NUMBER:
198602875
ADMINISTRATOR/
DIRECTOR:		HENRY A LARAFACILITY TYPE:
735
ADDRESS:3453 LIBERTY BOULEVARDTELEPHONE:
(562) 682-9667
CITY:SOUTH GATESTATE: CAZIP CODE:
90280
CAPACITY: 4CENSUS: 4DATE:
04/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:09 AM
MET WITH:Henry Lara - AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Tena Herrera conducted the required unannounced annual inspection. Upoon arrival there were no staff or clients at facility as clients were away at day program at approximatly 10am Administrator Henry Lara arrived to assist with the visit LPA explained the reason for the visit. Facility currently has 4 clients serviced by South Central Los Angeles Regional Center.

The facility is a single-story home located in a residential area in South Gate, Ca. A tour of the facility includes: living room, dining area, kitchen, staff restroom (1/2 bath with laundry), 3 client bedrooms (1 shared room), 1 full bathroom, detached garage, front yard and back yard.

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


Infection Control: Facility has sufficient PPE supplies and the required Infection Control Plan.
Physical Plant & Environment Safety: LPA toured facility, clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested in the client bathroom and was within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked and are inaccessible to clients. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged.
Operational Requirements: Facility has an activity area furnished for outdoor use.
Staffing: There appears to be sufficient staffing at all times in the facility.
(continued on 809-C)
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: CASA BARBARA
FACILITY NUMBER: 198602875
VISIT DATE: 04/22/2025
NARRATIVE
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Personnel Records-Training: Administrator Henry Lara maintains a valid certificate that expires on 10/31/25. There were no staff files readily available for review during todays visit citation will be issued and details can be found on the LIC809-D.
Client Rights-Information: Facility provides telephone landline and internet for the clients. Client rights posters and reporting posters are displayed within the facility.
Client Records-Incident Reports: Client files were not at facility or readily available for review during visit citation will be issued and details can be found on the LIC809-D.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers. LPA reviewed 4 clients medication during todays visit with no issues observed.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Facility maintains documentation of the required emergency drills, however, there was no proof of the required drills during todays visit. Technical Violation issued during todays visit, administrator to email copy of proof to LPA by end of business day.
Emergency Intervention: Clients at this facility do not need the use of restraints or de-escalation techniques.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during todays visit will be documented on the LIC809-D.

Exit interview was held and a copy of the report was given to Administrator Henry Lara.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/22/2025 10:59 AM - It Cannot Be Edited


Created By: Tena Herrera On 04/22/2025 at 10:42 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CASA BARBARA
FACILITY NUMBER: 198602875

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(e)
80066 Personnel Records (e) All personnel records shall be maintained at the facility site and shall be available to the licensing agency for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and attempted record review, the licensee did not comply with the section cited above as there were no personnel records readily available for review during todays visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2025
Plan of Correction
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Administrator/Licensee to develop a plan to have records readily available/maintained at the facility site for licensing agency to review during visits.
Type B
Section Cited
CCR
80070(a)
80070 Client Records (a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and attempted record review, the licensee did not comply with the section cited above as there were no clients records readily available for review during visit, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2025
Plan of Correction
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Administrator/Licensee to develop a plan to have records readily available/maintained at the facility site for licensing agency to review during visits.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Tena Herrera
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2025


LIC809 (FAS) - (06/04)
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