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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601880
Report Date: 08/26/2021
Date Signed: 09/01/2021 11:03:11 AM

Document Has Been Signed on 09/01/2021 11:03 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:LUBEC HOMEFACILITY NUMBER:
198601880
ADMINISTRATOR:SMYRNA DOJCINOVICFACILITY TYPE:
734
ADDRESS:9294 LUBEC STREETTELEPHONE:
(562) 923-0900
CITY:DOWNEYSTATE: CAZIP CODE:
90240
CAPACITY: 5CENSUS: 4DATE:
08/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Ayub WalayatTIME COMPLETED:
04:30 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 Ayub Walayat, RN Divina De Gala, LVN Rosalie Custodio, and DSP Lorna Rodriguez 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 562 923-0900.

The facility consist of five bedrooms(1 vacant), two bathrooms(1 staff), living room, dining room, kitchen and covered patio located in the back yard, attached garage(storage/laundry equipment/office supplies).

During the visit the Infection control domain was used and the following areas were observed/inspected: The facility had all postings at the front entrance, bathrooms, and throughout the facility. Hand sanitizing gel and masks were located at the entry of the facility. A Pre screening area with PPE supplies was observed upon entry into the facility.

LPA conducted a complete tour of the facility, and observe the feeding supplies. Resident medications, and medication logs were reviewed. The smoke detectors/carbon monoxide detector are operable. LPA observed 3 fire extinguishers(kitchen, garage, living room area). The water temperature was tested and measured 116.4 degrees F. The mitigation plan has been received and approved on 03/24/2021. visit.

Administrators certificate for Jacqueline U Wright #6045777735, expires on 10/19/21.

There were no deficiencies cited during todays visit. A copy of this report was given during the exit interview.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Nicol Wesley
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2021
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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