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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603525
Report Date: 03/02/2022
Date Signed: 03/02/2022 11:43:27 AM

Document Has Been Signed on 03/02/2022 11:43 AM - 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:LAMBERT PLACE, THEFACILITY NUMBER:
198603525
ADMINISTRATOR:ALVAREZ, EDUARDOFACILITY TYPE:
737
ADDRESS:13304 LAMBERT RDTELEPHONE:
(909) 631-8521
CITY:WHITTIERSTATE: CAZIP CODE:
90602
CAPACITY: 3CENSUS: 0DATE:
03/02/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Ashish Bhavsar, LicenseeTIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Galarza made an Announced visit and met with Licensee Ashish Bhavsar and Administrator Eduardo Alvarez to conduct a Pre-Licensing evaluation.

An application was submitted to Community Care Licensing Department (CCLD) for an initial application of an Adult Residential Facility (ARF) to serve developmentally disabled adults ages 18-59. The home will be an Enhanced Behavioral Support Home (EBSH).The requested capacity is for three (3) non-ambulatory residents. Structure: Facility is a single-story home consisting of three (3) bedrooms, two (2) full bathrooms, one (1) 1/2 bathroom, kitchen, dining room, living room, laundry area, office, delayed egress, and a 2-car detached garage with an activity room. There is an assembly/recreation area with a basketball court located in the rear of the property. The front and backyard have grassy areas. The backyard has a covered patio area with patio furniture. Bedroom Clients: All three (3) bedrooms will be private. Bedrooms are equipped with one bed, night-stand, chair, lamp, and overhead lightning. Bathrooms: Have a working toilet, wash basin, and bathtub. Linens & Hygiene Supplies: All beds had the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linens is stored in bedroom closets. Emergency Phone Numbers, Exit Plan: Emergency numbers are posted and readily available for review. Three (3) fully charged fire extinguishers are in place. Facility does have an operable land line telephone. Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils were observed locked and inaccessible. Adequate food supply is stored in the kitchen and consists of the following: 2-day perishables, and 7-day non-perishables. Smoke Detectors: There are electrical & inter-connected smoke detectors located in all bedrooms, common areas, and hallways. There is a fire door in the hallway leading into the bedrooms. Appliances: Refrigerator, oven, microwave, dishwasher and washer/dryer are in new condition. The residence is equipped with central heating and air conditioning. Toxins: Cleaning supplies, and toxins are locked only accessible to staff.

See LIC 809C for continuation of report.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2022
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: LAMBERT PLACE, THE
FACILITY NUMBER: 198603525
VISIT DATE: 03/02/2022
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Water Temperature: Hot water was tested in all bathrooms, and kitchen sink. Water temperature was not within normal limits 105 degrees Fahrenheit (40.5 degrees C) and not more than 120 degrees Fahrenheit (48.8 degrees C). Medication, First-Aid Kit & Book: Designated centrally stored medications cabinet, and the first-aid kit has been inspected which has at least the following: tweezers, scissors, antiseptic, bandages, gauze, thermometer; including a current First Aid manual. Clients & Staff Files: Designated area for files will be in the office. Pools/Jacuzzi & Pets: No bodies of water and no pets on these premises. Fire Clearance: Fire clearance is approved on 1/18/2022 for three (3) non-ambulatory residents. The facility has a sprinkler system. Component III: Component III was waived.

The following item must be corrected, and proof of correction shall be submitted to the CCLD office to the attention of LPA Galarza by March 16, 2022. If additional time is required to complete noted items to correct, then the applicant will request an extension in writing prior to the due date. Some items may require a follow up inspection for verification of correction.

1. Window coverings/curtains for all windows in the home.

An exit interview was conducted, and a copy of this report has been furnished to Licensee. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
LIC809 (FAS) - (06/04)
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