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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603094
Report Date: 09/22/2021
Date Signed: 09/22/2021 11:56:28 AM

Document Has Been Signed on 09/22/2021 11:56 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:LAVENDER HOME INCFACILITY NUMBER:
198603094
ADMINISTRATOR:CALINGASAN, SOCORROFACILITY TYPE:
735
ADDRESS:9428 PITKIN STTELEPHONE:
(626) 941-6088
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY: 4CENSUS: 3DATE:
09/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Socorro Calingasan, AdministratorTIME COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Administrator Socorro Calingasan and explained the purpose of the visit. There are 3 level 4I ambulatory developmentally disabled clients ages 18-59 in the home. The facility is a single story home licensed for 2 ambulatory and 2 non-ambulatory clients located in a residential neighborhood. It consists of 4 client bedrooms, 1 office room, 2 bathrooms, dining area, kitchen, living room, lounge room, backyard patio area, and attached garage. The last fire drill was conducted on 9/5/2021. Administrator certificate expires 4/1/2023.

The following were observed/inspected:
  • The interior and exterior physical plant was inspected.
  • COVID-19 Infection Control Practices and signs were observed in the entrance, common areas, hallways, bathrooms and resident rooms.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing. Furniture was observed to be at least 6 feet apart.
  • Each client's room is designated as a COVID-19 solation room if needed.
  • Three (3) centrally stored resident medication records were reviewed.
  • All staff were observed wearing mask.
  • Due to client's disability and behaviors only some of the clients in care wear masks.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
  • A posted Emergency Disaster Plan was observed.
  • Sufficient supply of Personal Protective Equipment (PPEs) was observed. .
  • Staff and resident files were not reviewed during today's visit.


There were no deficiencies cited.

Exit interview was conducted with Administrator Socorro Calingasan. A copy of the report was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2021
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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