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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191570600
Report Date: 11/07/2025
Date Signed: 11/07/2025 06:13:15 PM

Document Has Been Signed on 11/07/2025 06:13 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:DELHAVEN FAIRGROVE DAY LEARNING CENTERFACILITY NUMBER:
191570600
ADMINISTRATOR/
DIRECTOR:		SEAL, BOBBIEFACILITY TYPE:
775
ADDRESS:15145 FAIRGROVE AVE.TELEPHONE:
(626) 917-9789
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY: 60CENSUS: 38DATE:
11/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Osman Izzeldin, Associate DirectorTIME VISIT/
INSPECTION COMPLETED:
06:15 PM
NARRATIVE
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Licensing Program Manager (LPM) Fernando Fierros and Licensing Program Analyst (LPA) Elena Mallett conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Associate Director Osman Al-Sheikh Izzeldin, Associate Director Eric Benavidez and Program Director Sherin Syed and the purpose of the visit was discussed. 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 an Infection Control Plan and training policies.

Operational Requirements:


· A current Plan of Operation was observed
· 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, staff break room, staff restroom, men's restroom and women's restroom
· The interior and exterior physical plant was inspected.

See continuation Page LIC 809C
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 11/07/2025 06:13 PM - It Cannot Be Edited


Created By: Elena Mallett On 11/07/2025 at 04:06 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: DELHAVEN FAIRGROVE DAY LEARNING CENTER
FACILITY NUMBER: 191570600

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82064(d)
Administrator -Qualifications and Duties
(d) The administrator shall receive and document a minimum of 30 clock hours of continuing education every 24 months of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [one] out of [one] staff file,the Administrator's file did not contain a minimum of 30 clock hours of continuing education every 24 months of employment.
which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/17/2025
Plan of Correction
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Licensee will submit proof of Administrative Training to Licensing via the On-Duty Fax number by POC due date.
Type B
Section Cited
CCR
82068.2(h)(1)
Needs and Services Plan
(1) The licensee shall document the initial assessment based on information available at the time of the assessment. This information shall be maintained and brought current thereafter as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [1] out of [5) client files reviewed indicated that Client 1 did not contain Client's initial assessmentwhich poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/17/2025
Plan of Correction
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Licensee will submit proof of initial assessment for Client 1 to Licensing via the On-Duty Fax number by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Elena Mallett
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 11/07/2025 06:13 PM - It Cannot Be Edited


Created By: Elena Mallett On 11/07/2025 at 04:06 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: DELHAVEN FAIRGROVE DAY LEARNING CENTER
FACILITY NUMBER: 191570600

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82069(a)
Client Medical Assessments
(a) Prior to or within 30 calendar days following the acceptance of a client, the licensee shall obtain a written medical assessment of the client that determines the licensee's ability to provide necessary health-related services to the client. The assessment shall be used in developing the Needs and Services Plan.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review], the licensee did not comply with the section cited above in [1t] out of [5] client files reviewed. Client 1's file did not cotain a medical assessment which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/17/2025
Plan of Correction
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Licensee will provide a copy of medical assessment for C1 to Licensing via On-Duty Fax by the POC date.
Type B
Section Cited
CCR
82070(b)(8)
Client Records
(b) Each record must contain information including, but not limited to, the following: (8) Medical assessment, including ambulatory status, as specified in Section 82069(b).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [5] out of [6] client files ( Clients 1,2,3, 5 and 6) reviewed did not indicate client's ambulatory status which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/17/2025
Plan of Correction
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Licensee will submit medical assessments that contain client's #1, #2, #3. #5 and #6 ambulatory status signed and dated by a licensed medical professional to licensing via On-Duty Fax by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Elena Mallett
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2025


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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: DELHAVEN FAIRGROVE DAY LEARNING CENTER
FACILITY NUMBER: 191570600
VISIT DATE: 11/07/2025
NARRATIVE
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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.
Outdoor Space is provided and observed to be safe for client use.

Staffing:
· Sufficient staff observed to meet client needs.

Food Service:
· Day program does not provide food service.
Continued on LIC 809-C


Personnel Records/Staff Training:
· Administrator on record is not current. Licensee to submit a request to update Administrator along with Administrator qualifications. Deficiencies were observed. Refer to LIC 809-D, deficiency page.
· Staff have criminal background clearance and training.
· Staff (5) files were reviewed. Proof of staff training, health clearance, and 1st Aid/CPR observed.

Client Records/Incident Reports:


· A total of five (5) client files were reviewed. Deficiencies were observed. Refer to LIC 809-D, deficiency page.
· Required postings observed

See continuation Page LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: DELHAVEN FAIRGROVE DAY LEARNING CENTER
FACILITY NUMBER: 191570600
VISIT DATE: 11/07/2025
NARRATIVE
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Client Rights-Information:
· Sufficient space to accommodate both indoor and outdoor activities was observed.
· Clients’ rights were posted.

Incidental Medical Services:


· Emergency transportation available
· First Aid kit was fully stocked.
· Facility does not hold or assist with medications

Health Related Services:


· Clients do not bring medications to facility
· Staff on shift have First Aid and CPR certifications.

Disaster Preparedness:


· Emergency and Disaster Plan LIC 610D is in place.
· Last emergency drill conducted within the last 3 months 10/17/2025.

Prohibited Health Conditions
· No residents have prohibited health conditions.

Per California Code of Regulations, Title 22, deficiencies were cited. Exit interview was conducted and a copy of this Licensing report and Appeal rights were provided during visit. A plan of correction was discussed and agreed upon.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025
LIC809 (FAS) - (06/04)
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