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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592625
Report Date: 12/21/2023
Date Signed: 12/21/2023 03:43:25 PM

Document Has Been Signed on 12/21/2023 03:43 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 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: 39DATE:
12/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Eric Benavidez, associate DirectorTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Eric Benevidez, associate Director, who assisted with the visit and explained the reason for the visit. The facility serves developmental disabled clients, who are ages 18 through 59 years old. The facility is approved for 44 ambulatory and 6 non ambulatory clients. Annual fees are current. The program is vendorized through San Gabriel/Pomona Regional Center. The facility hours of operation are Mon - Fri, from 9AM-3:30 PM. Clients attend programs at the facility.

During the visit, the infection control domain tool was used, facility was toured, staff/clients interviews were conducted, and staff/clients records were reviewed. Medications were not reviewed since the facility did not handle medication. The day program only provided snacks to clients in care since they were served for less than 8 hours.

The day program is a two-story building which houses the administrative office on the second floor and the day program on the first floor. The first floor consists of a large open activity area and 2 bathrooms. Water temperature was measured and in a range of 109.3 to 109.9 degree F which is in compliance with Title 22 regulations. The second floor consists of kitchen, restroom, meeting room, four (4) offices, reception area and a storage room. All rooms have the required furniture and equipment necessary to conduct activities. The license does not operate beyond the conditions and limitations specified on the license, including the capacity limitation. Motor vehicles used to transport clients are maintained in a safe operating condition.
(continued in LIC 809 C-)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2023
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 SOUTH ACTIVITY CENTER
FACILITY NUMBER: 191592625
VISIT DATE: 12/21/2023
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All clients are protected against hazards within the program site. The bathrooms are clean and operational. The hot water temperature measured at 115.6 degrees Fahrenheit. Disinfectants and cleaning solutions are locked and inaccessible to clients.

The licensee provides care and supervision necessary to meet the client's needs/services specified in the admission agreement. The licensee ensures that clients are kept clean and dry. The day program remains free of odors. Smoke detectors and carbon monoxide detectors are tested, operable and in compliance. The licensee ensures safe and healthy indoor activity space for clients. The program administrator is at the program site and sufficient number of hours necessary to manage and administer the program is observed.

No deficiencies were cited per California Code of Regulations, Title 22. An exit interview was conducted, and a copy of this report was provided to Eric Benavidez, associate Director.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC809 (FAS) - (06/04)
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