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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006096
Report Date: 05/15/2024
Date Signed: 05/15/2024 02:44:12 PM

Document Has Been Signed on 05/15/2024 02:44 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:LOLA SENIOR GUEST HOMEFACILITY NUMBER:
306006096
ADMINISTRATOR/
DIRECTOR:
DINH, KEVIN DINOFACILITY TYPE:
740
ADDRESS:8681 LOLA AVENUETELEPHONE:
(714) 300-4540
CITY:STANTONSTATE: CAZIP CODE:
90680
CAPACITY: 6CENSUS: 5DATE:
05/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Kevin Dino DinhTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
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Licensing Program Analysts (LPAs) Jerome Haley and conducted an unannounced visit for the purpose of conducting a required one-year annual inspection. LPA Haley was greeted and granted entry by staff and explained the reason for the visit. Staff contacted Administrator (AD) Kevin Dinh who arrived a short time later and was present for the remainder of the visit.

During the inspection, LPA Haley observed all resident bedrooms and bathrooms. All resident bedrooms had the necessary elements and were in compliance with regulation guidelines. Hot water temperatures were measured in the range of 106.5 degrees Fahrenheit and 113.5 degrees Fahrenheit.

In the kitchen, knives and sharp objects are kept locked in a drawer. A perishable food supply that meets regulation requirements was observed in the refrigerator. A non-perishable food supply that meets regulation requirements was observed in the cabinets. Cleaning solutions are locked under the kitchen sink.

The garage is cluttered and used to store miscellaneous facility items: matts, wheelchairs, toilet paper, oxygen tanks, etc. There were no clear walkways available in the garage. On the side and directly behind the garage, there is a large amount of clutter and debris that need to be disposed of.

The backyard was organized, and free of clutter. There’s a shaded patio area with a table and chairs. The pool is surrounded by a self-closing and self-latching fence that meets regulation requirements.

A fully charged fire extinguisher was observed mounted on the wall in the kitchen and in the dining room areas. There are locked filing cabinets in the dining room area used to store resident medication, staff, and resident files. A first aid kit with all the required elements is in a filing cabinet near the main entrance.

Smoke carbon monoxide detectors tested operational.

During the inspection, LPA Haley reviewed, resident medication, and conducted interviews with residents and staff.

Continued on LIC809C

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2024
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: LOLA SENIOR GUEST HOME
FACILITY NUMBER: 306006096
VISIT DATE: 05/15/2024
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Due to time constraints, the annual inspection will be ended and will be continued at a later time. Deficiencies and Technical Violations observed and photographed during the tour of the physical plant, medication review, and discovered during interviews will be cited at the conclusion of the annual inspection.

An exit interview was conducted, and a copy of this report was provided to Administrator Kevin Dino Dinh

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
LIC809 (FAS) - (06/04)
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