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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006096
Report Date: 06/06/2024
Date Signed: 06/06/2024 04:41:22 PM

Document Has Been Signed on 06/06/2024 04:41 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:
06/06/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:55 PM
MET WITH:Kevin Dino DinhTIME VISIT/
INSPECTION COMPLETED:
04:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jerome Haley arrived to complete the required one-year annual visit that was started May 15, 2024. LPA Haley was greeted and granted entry by staff and explained the reason for the visit. A phone call was placed to Administrator Kevin Dino Dinh who arrived a short time later and was present for the visit.

During the visit, LPA Haley completed the inspection tool, and conducted a brief tour of the backyard to observe the corrections that were made after the inspection on May 15, 2024.

As a result of the annual inspection, a citation and a technical violation were issued.

An exit interview was conducted, and a copy of this report and appeal rights were provided to Administrator Dinh.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2024
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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Document Has Been Signed on 06/06/2024 04:41 PM - It Cannot Be Edited


Created By: Jerome Haley On 06/06/2024 at 03:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: LOLA SENIOR GUEST HOME
FACILITY NUMBER: 306006096

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
The facility shall be safe, celan, sanitary, and in good repair at all times. Maintenance shall include provisions of maintenance services and procedures for the safety and well-being or residents, employees and visitors.

This requirement is not met as evidenced by: during the tour of the physical plant LPA Haley observed clutter, debris, old furniture, and a backyard fence that was leaning into the neighboring property.
Deficient Practice Statement
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Based on observation, of the clutter behind the garage, on the side of the garage, and the backyard fence that was in disrepair, the licensee did not comply with the section cited above, which posed a potential health and safety risk to persons in care.
POC Due Date: 06/06/2024
Plan of Correction
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POC has already been completed. All the miscellaneous items have been removed from behind and the side of the garage. All old furniture has been removed form the pool area. The fence that was leaning into the neighboring property was removed.
No further action is needed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Luz Adams
LICENSING EVALUATOR NAME:Jerome Haley
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024


LIC809 (FAS) - (06/04)
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