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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603094
Report Date: 09/09/2025
Date Signed: 09/09/2025 12:29:59 PM

Document Has Been Signed on 09/09/2025 12:29 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: 3DATE:
09/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:11 AM
MET WITH:Socorro Calingasan, Administrator TIME VISIT/
INSPECTION COMPLETED:
12:42 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.

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:


The facility is in good repair inside and outside. The living room and dining room have sufficient lighting and sitting space. The kitchen was observed clean. The 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. The 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 and measured 114.4 – 116.9 degrees F., which is within the required 105-120 degrees F. Carbon monoxide detector were observed, tested, and in working condition. The fire extinguishers were last checked on 5/26/2025


3. Operational Requirements: The Program Design was reviewed. Fire clearance was approved by LA County Fire Department for (2) ambulatory clients and two (2) non ambulatory. Care and supervision to meet the clients’ needs was observed. Equipment for shade is at home and just requires it to be set up.

(continued on 809C)

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2025
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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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: LAVENDER HOME INC
FACILITY NUMBER: 198603094
VISIT DATE: 09/09/2025
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(continued from 809)
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 04/01/2027 Three (3) 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: Three (3) 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 a sufficient supply of 2-day perishable and 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. Three (3) 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 should find relocation site outside the immediate area.

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 Advisory provided. Exit interview was held and a copy of the report along with appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
LIC809 (FAS) - (06/04)
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