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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603095
Report Date: 08/31/2023
Date Signed: 08/31/2023 05:10:25 PM

Document Has Been Signed on 08/31/2023 05:10 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:
08/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:47 PM
MET WITH:Gil Calingasan, administratorTIME COMPLETED:
05:15 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. LPA discussed with Administrator about the purpose of today's visit.

The facility is licensed to serve four (4) developmentally disabled, ambulatory only clients, ages from 18 to 59 years old. San Gabriel Pomona Regional Center and Lanterman regional center provide cases management services to clients in this home. Annual fees are current. Administrator certificate is current and expiration date is 11/20/23.

For the inspection, CARE inspection tool was used, staff/clients interviews were conducted, staff/client file was reviewed; facility tour was conducted; food supply was reviewed; and medications were reviewed.

The home is located in a residential neighborhood in the city of Covina. 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 required two (2) days perishable and seven (7) days non- perishable are observed. Clients’ bedrooms have the required furnishing and in compliance. Adequate linen and personal hygiene supply are observed. Bathrooms are clean and operational. Smoke Detectors and carbon monoxide detectors were operable. Fire drill was conducted on 6/7/23. Fire extinguisher was fully charged. Comfortable temperature of 73 degree Fahrenheit for clients was maintained. Hot water temperature measured at 105.3 degrees Fahrenheit. Client beds were in good condition and had appropriate linens.
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.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2023
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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