198602013-10-10-2024-28-AS-THEA-D9X22H-20241010170045

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602013
Report Date: 10/10/2024
Date Signed: 10/10/2024 05:01:42 PM

Document Has Been Signed on 10/10/2024 05:01 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	LUBEC HOME II		FACILITY NUMBER:	198602013
ADMINISTRATOR:	AYUB WALAYAT		FACILITY TYPE:	734
ADDRESS:	10429 TRISTAN DR		TELEPHONE:	(310) 991-3245
CITY:	DOWNEY	STATE: CA	ZIP CODE:	90241
CAPACITY:	5	CENSUS: 5	DATE:	10/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Ayub Walayat - Administrator		TIME COMPLETED:	05:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Administrator Ayub Walayat and explained the purpose for today’s visit. The facility is licensed to serve (5) bedridden adults. The facility currently has (5) Non-Ambulatory client that are all serviced through South Central Los Angeles Regional Center (which were present and conducting their annual Q&A as well).

The facility is a single-story home located in a residential area in Downey, Ca. A tour of the facility includes: 5 bedrooms, 1 full bath, 1 half bath, living room, dining area, laundry area, detached garage, front yard and back yard.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility.
Physical Plant & Environment Safety: LPA toured facility, clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested in the client bathroom and was within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked cabinet and are inaccessible to clients. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged.

(Continued on LIC809-C)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LUBEC HOME II	FACILITY NUMBER: 198602013
	VISIT DATE: 10/10/2024

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Operational Requirements: Administrators are knowledgeable in their reporting requirements for the Adult Residential Facility for Persons with Special Health Care Needs and events that must be reported to licensing within either 2 hours or 24 hours of occurrence. Fire/Emergency drills are conducted monthly with the last drill dated 9/26/24..
Personnel Records-Training: Staff files are maintained in a secure location. LPA reviewed 4 staff files during today’s visit, files reviewed contained the following: Criminal Background Clearance, Health Screening Report, First-Aid/CPR/AED and sufficient on-going training. Ayub Walayat Administrator Certificate expired on 9/7/24, however, proof of renewal was provided and name appears on the CCL website pending list.
Client Records-Incident Reports: Client files are maintained in a secured locked cabinet and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. LPA reviewed 5 client files with no issues.
Client Rights-Information: Facility provides telephone landline for the clients. Client rights posters and reporting posters are displayed within the facility.
Food Service: All clients at this facility are G-tube fed and there was sufficient supply of liquid meals to meet the needs of the clients. Facility also has an emergency supply of perishable foods.
Health Related Service: Staff designated to administer medication have the proper annual training on file. Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers. Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Facility maintains documentation of the required emergency drills.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during todays visit.

Exit interview was held and a copy of the report will be emailed to Ayub Walayat.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

LIC809 (FAS) - (06/04)

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