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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191570600
Report Date: 12/07/2023
Date Signed: 12/07/2023 03:03:13 PM

Document Has Been Signed on 12/07/2023 03:03 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:DELHAVEN FAIRGROVE DAY LEARNING CENTERFACILITY NUMBER:
191570600
ADMINISTRATOR:SEAL, BOBBIEFACILITY TYPE:
775
ADDRESS:15145 FAIRGROVE AVE.TELEPHONE:
(626) 917-9789
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY: 60CENSUS: 37DATE:
12/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Assistant Director Izzeldine Osman TIME COMPLETED:
03:15 PM
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Licensing Program Analysts (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Assistant Director Izzeldine Osman . The following(CARE) tool domains were utilized during the inspection:

Infection Control:
  • Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. The facility has submitted a COVID-19 Mitigation Plan and has an Infection Control Plan.

Operational Requirements:
  • A current Plan of Operation was reviewed.
  • A fire clearance for 60 clients of which four (4) may be non ambulatory

Physical Plant/Environment Safety:
  • The facility is a single story facility containing the following: 2 Activity rooms, office, break room, quarantine room, staff restroom, men's restroom and women's restroom
  • The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to clients.
  • Water temperature readings measured within the required 105 - 120 degrees Fahrenheit.

Staffing:
  • A total of 22 staff members provide supervision to the clients.

Continued on LIC 809-C
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2023
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: DELHAVEN FAIRGROVE DAY LEARNING CENTER
FACILITY NUMBER: 191570600
VISIT DATE: 12/07/2023
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Personnel Records/Staff Training:
  • Administrator on record is current.
  • Staff have criminal background clearance and training.
  • Seven (7) staff files were reviewed. Proof of staff training, health clearance, and 1st Aid/CPR training was observed.

Resident Records/Incident Reports:
  • A total of six (6) client files were reviewed.
  • Required postings observed

Planned Activities:
  • Sufficient space to accommodate both indoor and outdoor activities was observed.
  • An activity calendar was reviewed

Food Service:
  • Sanitation practices and kitchen cleanliness was observed.
  • Kitchen has utensils for clients to use and to store their meals

Incident Medical and Dental:
  • Emergency transportation available
  • First Aid Kid observed
  • Facility does not hold or assist with medications

Disaster Preparedness:
  • Emergency and Disaster Plan LIC 610E is in place.
  • Last emergency drill conducted 9/27/23

Residents with Special Health Needs:
  • Facility has IPP's for all clients
  • No residents have prohibited health conditions.

Per California Code of Regulations, Title 22, NO deficiencies were cited. Exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023
LIC809 (FAS) - (06/04)
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