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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592625
Report Date: 11/14/2024
Date Signed: 11/14/2024 03:19:17 PM

Document Has Been Signed on 11/14/2024 03:19 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/
DIRECTOR:		SEAL, BARBARAFACILITY TYPE:
775
ADDRESS:15135 FAIRGROVE AVE.TELEPHONE:
(626) 917-9789
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY: 50CENSUS: 21DATE:
11/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:01 PM
MET WITH:Staff Eric BenavidezTIME VISIT/
INSPECTION COMPLETED:
03:30 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. LPA met with Staff Eric Benavidez 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 two-story facility. The first floor contains (1) Activity room and (2) restrooms. The 2nd floor contains offices for staff and a staff kitchen. There is a backyard for client use.
  • 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.
  • Outdoor Space is provided and observed to be safe for client use.

Staffing:
  • Sufficient staff observed to meet client needs.


Food Service:
  • cleaning supplies and Toxins are stored separate from client meals
Continued on LIC 809-C
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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: 11/14/2024
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Personnel Records/Staff Training:
  • Administrator on record is current.
  • Staff have criminal background clearance and training.
  • Six (6) staff files were reviewed. Proof of staff training, health clearance, and 1st Aid/CPR observed.

Client Records/Incident Reports:
  • A total of four (4) client files were reviewed.
  • Required postings observed

Client Rights-Information:
  • Sufficient space to accommodate both indoor and outdoor activities was observed.
  • An activity calendar was reviewed

Incidental Medical Services:
  • Emergency transportation available
  • First Aid Kid observed
  • 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 610E is in place.
  • Last emergency drill conducted within the last 3 months

Emergency Intervention:
  • 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: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC809 (FAS) - (06/04)
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