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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603094
Report Date: 09/29/2023
Date Signed: 09/29/2023 02:50:47 PM

Document Has Been Signed on 09/29/2023 02:50 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: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:
09/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:22 AM
MET WITH:Socorro Calingasan - AdministratorTIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility using the CARE Tool. LPA Mora met with Socorro Calingasan (Administrator) and explained the reason for the visit. The facility is licensed to serve 4 ambulatory clients of which 2 may be non-ambulatory in the age range of 18-59. The facility is operating within the scope of its license.

A tour of the single-story facility included: 4 client bedrooms, 1 staff bathroom, 1 client bathroom, kitchen, dining room, living room, office room, lounge area, backyard, attached garage. LPA Mora conducted the tour with Socorro Calingasan and observed the following: sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were observed in the kitchen. Sharps are kept locked under the kitchen sink. Cleaning solutions are kept locked in the garage. The First Aid kit is kept locked in the medication cabinet and it is fully stocked with all required items including a current manual. Clean towels and extra clean linen were observed in each bedroom. Dining and living room have sufficient lighting and sitting area. Medications are kept locked in a kitchen cabinet. Client files are kept in a living room cabinet and staff files are kept in the office room. All bedrooms have all required furniture, lighting, and bedding. All bathroom showers were observed to have non-skid material and have the required grab bars for non-ambulatory clients. The water temperature was tested in both bathrooms and measured at 113.7 degrees F and 113.3 degrees F, which is within the required 105-120 degrees F. A fire extinguisher was observed in the kitchen and hallway, and were fully charged. Smoke detectors were observed throughout the facility and were operable during the visit. A carbon monoxide was observed in the living room and was operable during the visit. The front yard and backyard are clean. There is a shaded area with seating in the backyard. No bodies of water were observed at the facility. Passageways and exits are free of obstruction.

LPA reviewed medication for all 3 clients and observed that medications are documented properly and given as prescribed. LPA reviewed files for all 3 clients and 5 staff. No issues were observed with the files. LPA interviewed 2 staff and 2 client. LPA reviewed P&I funds for 2 clients. The third client's funds is managed by the family. (Continued to LIC 809-C)
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2023
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: LAVENDER HOME INC
FACILITY NUMBER: 198603094
VISIT DATE: 09/29/2023
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Per California Code of Regulations, Title 22, and California Health and Safety Code, there are no deficiencies observed during the visit. Exit interview held and a copy of the report were provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
LIC809 (FAS) - (06/04)
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