Facility Evaluation Report

On 11/25/2025 at approximately 08:00 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced annual visit to the facility. LPA was greeted by Co-Administrator, Dacia Von Buck and stated the reason for their visit.

LPA asked for the census and Staff/Client Roster. LPA conducted a physical plant tour at approximately 09:00 AM and the following was noted:

The facility is a single unit building with three (3) bedrooms and three (3) bathrooms currently occupying three (3) clients. There is one (1) designated staff room with its own bathroom. The facility has an approved fire clearance for four (4) ambulatory clients. The facility is vendor through North Los Angeles Regional Center (NLARC) and is being operated at a Level II Adult Residential Home.

Common areas: The living room and dining room were observed to be neat, clean, and organized. The rooms were observed to be properly furnished and in good repair. The facility maintains a comfortable temperature at 68°F. LPA observed a fire extinguisher to be located in the living room and dated 05/26/2025. LPA observed required postings such as See/Say Something, Facility License, and Personal Rights located throughout the common areas. A working telephone was observed. LPA observed a fireplace to be covered and inaccessible to clients.

Kitchen: The kitchen was observed to be clean and free from pests. Sufficient supplies of seven (7) day nonperishable foods and two (2) day perishable foods were observed. Kitchen appliances were observed to be working and in proper condition. The knives/sharps were observed to be kept within a locked box inside of a locked filing cabinet located in the staff reception area. (continued on LIC 809-C)