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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003988
Report Date: 10/06/2025
Date Signed: 10/06/2025 11:27:20 AM

Document Has Been Signed on 10/06/2025 11:27 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:LUCKY HOMES 2FACILITY NUMBER:
306003988
ADMINISTRATOR/
DIRECTOR:		VERONICA YUCONFACILITY TYPE:
735
ADDRESS:16719 ERIC STREETTELEPHONE:
(562) 219-7037
CITY:ARTESIASTATE: CAZIP CODE:
90703
CAPACITY: 4CENSUS: 4DATE:
10/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:54 AM
MET WITH:Linda Jade Mujemulta, Direct Support ProfessionalTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced required annual visit today. LPA met with Linda Jade Mujemulta, Direct Support Professional and the reason for the visit was explained. Veronica Karen Andaya, Administrator, arrived there after and assisted with today’s visit.

The facility is licensed to serve (4) developmentally disabled adults, ages 18 through 59; ambulatory only. The facility is operating within the scope of its license. Clients receive services through the Harbor Regional Center. The single-story home is in a residential area of Artesia and it consists of living room, dining room, kitchen, (4) client bedrooms, (1) staff room/office, (2) full bathrooms, attached garage, front and backyard, patio and outdoor laundry area.

During today’s visit, LPA observed the following:

The facility is clean inside and out. Passageways, walkways and exits are free of debris and obstructions. The living room and dining room have sufficient seating for clients, and the furniture is in good repair. The kitchen is clean and sanitary. Canned and dry food is labeled and kept within expiration limits. Sufficient supply of 2 days perishable and 7 days non-perishable foods was observed. An overflow refrigerator and an additional pantry are kept in the garage and contain extra food for clients and staff. Sharps/knives are kept locked in a kitchen drawer and cleaning supplies are kept locked under kitchen sink. Client bedrooms are clean and have the required furniture and bedding. Bedrooms have ample closet space and extra linen for client beds is stored in the hallway closet. Both bathrooms were inspected and observed clean and sanitary. Showers have safety grab bars, shower chairs and anti-slip mats. Water temperature was tested in both bathrooms and measured between 105-120 degrees F. which is within compliance range. Front and backyard are well maintained. The backyard has a shaded area with sufficient seating and patio furniture is in good repair. No pools or large bodies of water were observed. Garage is kept clean and cabinets containing toxins were locked. Laundry area in the backyard is kept clean, and appliances were operating at the time of visit. Detergents and softeners are inaccessible to clients. ***Continues on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2025
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: LUCKY HOMES 2
FACILITY NUMBER: 306003988
VISIT DATE: 10/06/2025
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Four (4) staff files were reviewed and contained criminal background clearances, health and TB screenings and training documentation. Four (4) client files were also reviewed and contained physician reports, TB clearances and the required documentation to maintain compliance. Medication is centrally stored in the staff office, and it is kept locked and inaccessible to clients. Medication was reviewed and observed to be administered as prescribed and documented accordingly.

Fire extinguisher is kept in the dining area and is charged and operable. Smoke detectors were observed throughout the facility and were tested and are working properly. Carbon monoxide detector was also tested and is working properly. Facility conducts safety drills each month and last drill was conducted on 9/20/25. The home is equipped with a back-up generator which is kept covered in the backyard. Generator is tested every other month by staff. Facility’s Emergency Preparedness and Infection Control Plans are up to date.

Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies are cited today. Exit interview conducted with Veronica Karen Andaya, Administrator and a copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2025
LIC809 (FAS) - (06/04)
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