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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603094
Report Date: 09/21/2022
Date Signed: 09/21/2022 04:57:12 PM

Document Has Been Signed on 09/21/2022 04:57 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: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:
09/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Joji Jonson, StaffTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection with the focus of the Infection Control domain. LPA met with Joji Jonson, Staff, and explained the purpose of the visit. The facility is licensed for 4 clients, ages 18 through 59, of which 2 may be non-ambulatory. There are currently 3 clients placed by the Eastern Los Angeles Regional Center.

LPA toured the facility and observed the following:
* The single story home has 4 client bedrooms, 1 office room, 2 bathrooms, living room, lounge area, kitchen, and attached garage. There are no pool or bodies of water at the premises. Each client has a private room.
* The facility has a PPE station right outside the door. Staff continue to screen all visitors and document on the sign-in log.
* COVID-19 signage are posted at the door and throughout the home including bathrooms.
* The house is kept clean and per staff, they clean and sanitize every 2 hours.
* Sufficient PPE supplies are kept in the office and garage, as well as cleaning/disinfectant products.
* The fire extinguishers were last inspected on 4/18/22.
* The hot water temperature was measured in bathroom #1 at 135.7 degree F and bathroom #2 at 136 degree F which is above the required range of 105 to 120 degree.
* Sufficient supplies of 2 day perishable and a week of nonperishable were observed.
* Staff were wearing face masks.
* There are smoke detectors located throughout the home and one observed in each client's room. The smoke detectors and the carbon monoxide detector were tested and operable.
* Medications were reviewed for all 3 clients and no discrepancies were observed.

A deficiency is issued on the LIC9099D page. An exit interview was held. A copy of this report along with appeal rights were given to the Staff Joji.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2022
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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Document Has Been Signed on 09/21/2022 04:57 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 09/21/2022 at 04:34 PM
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: LAVENDER HOME INC
FACILITY NUMBER: 198603094

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
80088 Furniture, Fixtures, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water.
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in both bathrooms where the hot water was measured at 135.7 degree F (bathroom #1) and 136 degree F (bathroom #2) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/22/2022
Plan of Correction
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The licensee shall adjust the hot water termperature to a lower range and record the water temperature at different hours during the 24 hour period to ensure it falls between the required range. The hot water log shall be submitted to LPA by due date 9/22/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022


LIC809 (FAS) - (06/04)
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