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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603318
Report Date: 12/10/2021
Date Signed: 12/13/2021 08:57:15 PM

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:DIGNITY CARE HOME - TWOFACILITY NUMBER:
198603318
ADMINISTRATOR:LOBARBIO, CHARLENEFACILITY TYPE:
740
ADDRESS:12323 VIARNA STREETTELEPHONE:
(562) 682-4330
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY:4CENSUS: 0DATE:
12/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Charlene LobarbioTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Nicol Wesley conducted an unannounced Required 1 year inspection at the facility and met with Administrator Charlen Lobarbio and explained the purpose for todays visit. Prior to the visit LPA Wesley conducted a risk assessment for on-site inspections. The facility phone number is 562 682 4330.

The facility consist of five resident bedrooms(3 upstairs), two bathrooms(1 upstairs), a living room, dining room, kitchen and patio located in the back yard, attached garage(washer and dryer). LPA observed social distance postings in the dining room area.

There are currently no clients in care. The facility mitigation plan was reviewed and approved on 07/19/2021.
LPA conducted a complete tour of the facility, LPA observed one fire extinguisher in the dining room area. The water temperature was tested. Food items were observed and PPE supplies were observed.

There were no deficiencies cited.

Exit interview conducted.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
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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