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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592625
Report Date: 12/01/2022
Date Signed: 12/01/2022 11:54:38 AM

Document Has Been Signed on 12/01/2022 11:54 AM - 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 SOUTH ACTIVITY CENTERFACILITY NUMBER:
191592625
ADMINISTRATOR:SEAL, BARBARAFACILITY TYPE:
775
ADDRESS:15135 FAIRGROVE AVE.TELEPHONE:
(626) 917-9789
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY: 50CENSUS: 18DATE:
12/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Izzeldin Abdelrhman Al-Sheikh Osman (Associate Director)TIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Kruz Long conducted an unannounced annual inspection at the facility. Upon arrival, LPA met with Izzeldin Abdelrhman Al-Sheikh Osman (Associate Director) and explained the purpose of the visit. LICENSEE PREFERS TO SERVE DEVELOPMENTAL DISABLED CLIENTS AGES 18 THRU 59 YEARS OLD. CLEARED FOR 44 AMBULATORY & 6 NON-AMBULATORY CLIENTS. HOURS M-F 9:00 AM-3:30 PM.

The 2 story facility contains the following: 1st floor: Activity Room, 1 men's restroom and 1 women's restroom. 2nd floor: Kitchen, restroom, meeting room, 4 offices, reception area and a storage room.

During today's inspection, LPA observed the following: Licensee is not operating beyond the conditions and limitations specified on the license, including the capacity limitation. Motor vehicles used to transport clients is maintained in a safe operating condition. All clients are protected against hazards within the program site. Disinfectants, cleaning solutions, poisons are locked and inaccessible to clients. Hot water temperature measured at 114.8 degrees F in the men's restroom. All toilets and hand washing basin is maintained in a safe, sanitary, operating condition. Clients in care for less than 8 hours is provided snacks. The licensee does provide care and supervision necessary to meet the client's needs and all services specified in the admission agreement. The licensee ensures that clients are kept clean and dry and the day program remains free of odors. Program personnel is sufficient in numbers to provide the services necessary to meet individual client needs. The written Needs and Services Plan is maintained in the client's file. Staff subject to a criminal record has a clearance. Disaster drills was conducted and documented at least every 6 months. Staff responsible for direct care and supervision have current First Aid and CPR. Outdoor activity space is provided, it is free of hazards. The licensee ensures safe and healthy indoor activity space for clients. The administrator is at the program site the number of hours necessary to manage and administer the program.

No deficiencies were observed during today's visit.
An exit interview was conducted with Izzeldin Abdelrhman Al-Sheikh Osman and a copy of this report provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2022
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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