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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603095
Report Date: 10/14/2022
Date Signed: 10/14/2022 04:52:00 PM

Document Has Been Signed on 10/14/2022 04:52 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
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: 2DATE:
10/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Gil Calingasan, AdministratorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection. LPA met with Gil Calingasan, Administrator, who assisted with the visit. The facility is licensed to serve four (4) developmentally disabled, ambulatory only clients, (age 18-59). San Gabriel Pomona Regional Center provides case management service to client residing in this home. The annual fee is current. Administrator certificate is current and expiration date is 11/20/23. 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, staff interview and client interview; staff and client file was reviewed; a tour of the facility was conducted; food supply was reviewed; and medications were reviewed.

The home is located in a residential neighborhood within the city of Covina. LPA toured the facility inside and outside. The facility is a single family home 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 operable. Clients’ bedrooms have beds, dressers, chairs and closet space available. Adequate linen and personal hygiene supply are observed. Bathrooms are clean and operational. Common areas including the kitchen, living room, and dining room were inspected. Administrator tested the Smoke Detectors and carbon monoxide detectors were operable. Fire drill was conducted on 8/18/22. Fire extinguisher was fully charged and last service was 4/18/22. 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 117.0 degrees Fahrenheit. Client 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: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2022
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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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: 10/14/2022
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Pesticides/poisons were not stored in food areas, kitchen, or where kitchen equipment/utensils were stored.

Medications cabinet in the living for centrally store the medication is observed and inaccessible to the clients. Medication log is current. Hazardous / sharp items were locked and inaccessible to clients.

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

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: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022
LIC809 (FAS) - (06/04)
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