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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603094
Report Date: 09/12/2024
Date Signed: 09/12/2024 03:52:07 PM

Document Has Been Signed on 09/12/2024 03:52 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/
DIRECTOR:		CALINGASAN, SOCORROFACILITY TYPE:
735
ADDRESS:9428 PITKIN STTELEPHONE:
(626) 941-6088
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY: 4CENSUS: 4DATE:
09/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:47 PM
MET WITH:Socorro Caligasan, Administrator TIME VISIT/
INSPECTION COMPLETED:
04:09 PM
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced annual visit at the facility using the CARE tool. LPA met with Socorro Caligasan, Administrator and explained the reason for the visit.

Facility is licensed to served 4 adults between the ages of 18-59 years old.

The following was observed:

1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. Facility is disinfecting throughout the day.

2. Physical Plant/Environment Safety:


Facility is in good repair inside and outside. Living room and dining room have sufficient lighting and sitting space. Kitchen was observed clean. Medication cabinet is locked. Cleaning supplies are under lock and key. There are sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables. Temperature in freezer and refrigerator where within range. Laundry area is in the back area of home. Client's bedrooms were observed and have sufficient lighting, the required furniture and bedding supplies. Bathrooms were observed in working condition and water temperature was tested between 109.5 – 113.3 degrees F., which is within the required 105-120 degrees F. Carbon monoxide detector were observed, tested, and in working condition. Fire extinguisher was last checked on 4/16/2024


3. Operational Requirements: The Program Design was reviewed. Fire clearance was approved by LA County Fire Department for (4) ambulatory clients. Care and supervision to meet the clients’ needs was observed. Equipment for shaded are is at home and needs to be set up.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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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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: 09/12/2024
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4) Staffing: A total of six (6) staff members provide care and supervision to the clients.

5. Personnel Records/Staff Training: Administrator’s certificate expires 04/01/2025 Staff files were reviewed for criminal background clearance and training. Personnel records have health/TB screenings and 1st Aid/CPR training.

6. Client Rights/Information: Personal rights are posted near the entrance.

7. Client Records/Incident Reports: Four (4) client files were reviewed containing admission agreements, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent.

8. Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

9. Health Related Services: Clients are assisted with self-administration of prescription and non-prescription medications. Four (4) centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked area and not accessible to clients in care. Medications are given according to Physician orders.

10. Incident Medical and Dental: All clients have a Needs and Services Plan, and COVID-19 vaccination cards on file.

11. Disaster Preparedness, and Emergency Intervention: A posted Emergency Disaster Plan LIC 610D containing emergency evacuation information was observed but facility needs to train staff on location and instructions of shutting off utilities.


12. Emergency Intervention: No manual restraints or seclusion are used with clients in care.


Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies observed during the visit. Technical Advisories provided. Exit interview held and a copy of the report along with appeal rights were provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
LIC809 (FAS) - (06/04)
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