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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604547
Report Date: 03/30/2022
Date Signed: 03/30/2022 05:20:00 PM

Document Has Been Signed on 03/30/2022 05:20 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:L & M RESIDENTIAL #2FACILITY NUMBER:
374604547
ADMINISTRATOR:LARA, OSCARFACILITY TYPE:
735
ADDRESS:9028 DAVENRICH ST.TELEPHONE:
(619) 778-8949
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 4CENSUS: 0DATE:
03/30/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Oscar Lara, AdministratorTIME COMPLETED:
10:35 AM
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Licensing Program Analyst (LPA), Tiffany Holmes conducted an announced Pre-Licensing visit to observe the facility's compliance with Title 22, Division 6 regulations and the California health and code. LPA met with Administrator, Oscar Lara. Facility is applying to serve four (4) clients 18-59 years of age. (4) rooms at the facility are approved for non-ambulatory use.

During today's visit LPA, accompanied by Administrator Oscar conducted a facility tour. LPA observed resident rooms and found them to have proper furnishings, and adequate linens. Sinks accessible to residents had running water. Facility temperature was read at 66 degrees Fahrenheit. Facility had a working fire extinguisher. Smoke and carbon monoxide alarms were observed and operational. The Fire Department granted clearance on 02/10/2022. Administrator stated that there will be no weapons or ammunition kept on the facility property. Staff and resident records will be stored in a locked cabinet. There is a shaded outdoor space and appropriate resident activities. All cleaning supplies or potentially hazardous materials were locked. Facility has a locked area for resident medications and first aid kits. Administrator Certificate expires on 06/11/2022 . Component III was reviewed with the Administrator. The application will be sent to the Centralized Application Bureau for final review and approval.

An exit interview was conducted with Administrator, Oscar Lara . A copy of this report and Licensee Appeal Rights (LIC 9058 01/16) was provided vie email. An electronic read receipt confirms receipt of these documents.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2022
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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