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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603095
Report Date: 08/20/2021
Date Signed: 08/20/2021 12:24:33 PM

Document Has Been Signed on 08/20/2021 12:24 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:LILAC CARE RESIDENTIAL HOME LLCFACILITY NUMBER:
198603095
ADMINISTRATOR:CALINGASAN, GILFACILITY TYPE:
735
ADDRESS:16502 E QUEENSIDE DRTELEPHONE:
(213) 388-2229
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY: 4CENSUS: 1DATE:
08/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Staff, Eric Ventura
Administrator, Gil Calingasan		TIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Tao, conducted an unannounced annual inspection. The facility is licensed to serve four (4) Developmentally Disabled Ambulatory only clients, (age 18-59). Client census is one (1). LPA was allowed entry by the facility staff. San Gabriel Pomona Regional Center provides case management service to client residing in this home. The annual fee is paid. LPA met with Gil Calingasan, Administrator, and Eric Ventura, staff who assisted with the visit. LPA discussed with Administrator about the purpose of today's visit.

During the visit, the following domain of the new inspection tool was used: infection control domain;
a tour of the facility conducted; food supply was reviewed; and medications were reviewed.

LPA toured the facility inside and outside. The home is located in a residential neighborhood within the city of Covina and is a one story building which consists of three (3) client bedrooms, two (2) bathrooms, living room, activity room, dining room, kitchen, and detached garage. The kitchen is clean and has maintained the required two (2) days perishable and seven (7) days non- perishable. All burners and stove tops were in working condition. Clients’ bedrooms have beds, dressers, chairs and closet space available. Adequate linen and personal hygiene supply are observed. Bathrooms are clean and operational.

LPA also inspected facility common areas including the kitchen, living room, and dining room. Administrator tested the Smoke Detectors and carbon monoxide detectors were operational. Fire drill was conducted on June 8, 2021. Fire extinguisher was fully charged. The first aid kit was fully stocked with a manual. Comfortable temperature of 73 degree Fahrenheit for clients was maintained. Hot water temperature measured at 105.5 degrees Fahrenheit. Resident beds were in good condition and had appropriate linens. Lamps/lights for each room were available to ensure the safety and comfort of all persons in the facility.

(-continued in LIC 809 C-)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: LILAC CARE RESIDENTIAL HOME LLC
FACILITY NUMBER: 198603095
VISIT DATE: 08/20/2021
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Pesticides/poisons were not stored in food areas, kitchen, or where kitchen equipment/utensils were stored.

Medications were centrally stored, locked in a cabinet located in the kitchen. Medications were properly logged and current. Hazardous items were locked and inaccessible to clients.

Administrator certificate is current and the expiration date is 11/20/21.



No deficiencies cited per California Code of Regulations, Title 22, Division 6.

An exit interview was conducted. This report is discussed and provided to facility Administrator, whose signature on this form confirm receipt of these documents.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
LIC809 (FAS) - (06/04)
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