306003762-12-2-2025-22-AS-RMRT-DNYQGS-20251202111001

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003762
Report Date: 12/02/2025
Date Signed: 12/02/2025 11:10:11 AM

Document Has Been Signed on 12/02/2025 11:10 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	LAWANDA HOME II		FACILITY NUMBER:	306003762
ADMINISTRATOR/ DIRECTOR:	DANTE BENEDICTO		FACILITY TYPE:	735
ADDRESS:	1758 BRENTWOOD PLACE, W.		TELEPHONE:	(657) 201-3148
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92804
CAPACITY: 6		CENSUS: 4	DATE:	12/02/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Dante Benedicto, Administrator		TIME VISIT/ INSPECTION COMPLETED:	11:30 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Staff #1 (S1) at 8am LPA met with Administrator (AD) Dante Benedicto and explained the purpose of the visit. The facility is a level 3, two- story home with four client bedrooms and one staff bedroom downstairs and two rooms upstairs which are occupied by the administrator. The facility has an approved fire clearance of six non-ambulatory and currently has a census of four clients in care. At time of arrival, all four clients had left for Adult Day Programs. During the visit, LPA toured the facility and tested auditory alarms on exits, smoke and carbon monoxide detectors and hot water temperatures in four of four resident bathrooms. The hot water temperature measured between 107.2 to 110.1 degrees Fahrenheit and all smoke and carbon monoxide detectors were operational. There is one camera in the dining room area that does not record audio. Client bathrooms and bedrooms were clean and had the required linens and furniture. LPA observed a screen door needed repair. The fire extinguisher is charged and was serviced on June 12, 2025 and the last fire drill was conducted on October 25, 2025. While touring the kitchen, LPA observed sharps and knives were secured. All appliances were operational and pantries were stocked with unexpired canned goods. The weekly menu was posted on the refrigerator and the facility had the required two-day perishables and seven-day non-perishables on-hand. Hazardous chemicals were locked and stored in the garage. A washer and dryer were in working order and emergency food supply and water were stored in the garage. A shaded seating was observed outdoors with a large exterior area for activities. (Continued on LIC 809-C)

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: RoseMarie Ruppert
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: LAWANDA HOME II	FACILITY NUMBER: 306003762
	VISIT DATE: 12/02/2025

NARRATIVE

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(Continued from LIC 809)

Staff and LPA audited medications for four of four clients. Medications are being given as prescribed. The First Aid Kit was mounted on the wall and had the required elements and a First Aid CPR Manual was located in the dining room.

LPA reviewed three of three staff training and fingerprint records and conducted a complete review of client records. Four of four client Admissions Agreements did not comply with Title 22 Regulations and a citation will be given. Client P&I records were reviewed and were accurate. LPA was not able to interview the four clients since all four clients were at their respective Day Programs. LPA interviewed staff regarding care provided to the clients. Staff training records were reviewed and all First Aid/ CPR certifications are current. LPA confirmed that administrator has a current administrator certificate which expires on July 15, 2027.

The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.
An exit interview was conducted with Dante Benedicto, Administrator and a copy of this report was given to the facility along with a copy of the LIC 858, LIC 859; LIC 809-D and Appeal Rights.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: RoseMarie Ruppert
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/02/2025 11:10 AM - It Cannot Be Edited

Created By: RoseMarie Ruppert On 12/02/2025 at 10:43 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: LAWANDA HOME II	FACILITY NUMBER: 306003762
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation and interview, the licensee did not comply with the section cited above with one of one client's screen door which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/31/2025
	Plan of Correction
1 2 3 4	AD will replace the screen and will text a picture of the fixed screen door to LPA by POC due date.

Type B

Section Cited

CCR

80068(a)

Admission Agreements

(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA record review, observations and interviews the licensee did not comply with the section cited above in four of four client files which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/16/2025
	Plan of Correction
1 2 3 4	AD will scan and email four of four client Admissions Agreements that comply with Title 22 Regulations by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:

	RoseMarie Ruppert
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/02/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025

LIC809 (FAS) - (06/04)

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