198600781-3-7-2024-11-AS-DESA-D362N5-20240307163210

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600781
Report Date: 03/07/2024
Date Signed: 03/07/2024 04:32:16 PM

Document Has Been Signed on 03/07/2024 04:32 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	DELIGHT SOME LAND		FACILITY NUMBER:	198600781
ADMINISTRATOR:	ALLEN D HAWKINS		FACILITY TYPE:	735
ADDRESS:	13313 ROSELLE AVENUE		TELEPHONE:	(310) 644-0420
CITY:	HAWTHORNE	STATE: CA	ZIP CODE:	90250
CAPACITY: 4		CENSUS: 2	DATE:	03/07/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:27 PM
MET WITH:	Administrator-ALLEN D HAWKINS		TIME COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 03/07/2024 at 2:15 pm Licensing Program Analyst (LPA) David España conducted an unannounced required annual visit. Upon arrival at the facility, LPA España met with Administrator, Allen Hawkins and explained the purpose of this visit. The facility is licensed for four (4) ambulatory developmentally disabled clients ages 18-59 years of age. Currently there are 2 client living in the facility. Clients were present during the visit, coming from the day program. The purpose of today’s visit was discussed. Upon arrival at the facility, LPA conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection. LPA was granted access and allowed to enter the facility to conduct inspections. The facility is a single-story home in a residential neighborhood. It consists of (2) client bedrooms, (1) bathroom, living room, dining room/den, kitchen, staff room, office area and an outdoor covered patio, backyard, an de-attached garage, and 2 storage sheds. LPA and the Administrator toured the facility, inside and out. Outside LPA observed a covered patio with table and chairs for client use. The Administrator has a worktable behind the house and 3 locked sheds with work supplies. In the garage is facility storage, cleaning supply, staff and client files, paper goods and additional PPEs. All walkways were clean, clear, and free of obstructions, hazards, and debris. LPA did not observe any bodies of water on the premises. Continued LIC 809-C

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: DELIGHT SOME LAND	FACILITY NUMBER: 198600781
	VISIT DATE: 03/07/2024

NARRATIVE

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All rooms were inspected. Bedrooms are private. All rooms have the required furniture including a bed, dressers, nightstand, chair, and storage for personal belongings. Beds and bedding supplies were in good condition. All beds have the required linens including mattress cover, fitted sheets, blankets, comforter and pillows. Client rooms had adequate lighting. LPA checked the bathroom. LPA observed sufficient liquid soap and paper towels. Toilets, water faucets, and shower worked properly. The grab bars were securely fastened. The shower had nonskid material on the bottom. LPA observed the shower to be free of mold/mildew. The water temperature measured at 117 degrees Fahrenheit. LPA observed and adequate supply of linens and towel in the cupboard in the hallway. Additionally in the hall cupboard is a supply of paper goods and hygiene products. LPA toured the kitchen area and observed it to be sanitary and clean. LPA observed a three-day supply of perishable and a seven-day supply of non-perishable foods. All food items were observed to be within their original packaging and within their expiration dates. LPA observed an ample supply of cutleries, pots, and pans to be in good repair. All appliances were observed to be fully functioning and in good repair. Knives and sharps are secured in a cabinet in the den. All cleaning supplies are secured under the sink and toxins were kept in the locked garage. LPA and Administrator toured all common rooms. All rooms have ample seating to accommodate clients and visitors. All hallways and doorways were clean, clear, and free of obstructions and hazards. LPA observed games and activities for residents. LPA observed a fireplace in the den covered by a screen and inaccessible to clients. A comfortable temperature was maintained in the facility.Continued LIC 809-C

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: DELIGHT SOME LAND	FACILITY NUMBER: 198600781
	VISIT DATE: 03/07/2024

NARRATIVE

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Interconnected Carbon Monoxide and Smoke Detectors were tested. LPA observed an additional 3 Carbon Monoxide detectors throughout the facility. LPA observed a brand new (with receipt) fully charged fire extinguisher in the kitchen. The last emergency drill was conducted in 01/11/24. LPA observed a working landline telephone. LPA observed a First Aid Kit fully stocked with required item and a manual. LPA observed all required postings in the den and staff office space. LPA was informed there are no firearms or ammunition stored on the premises.
During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance. LPA reviewed the resident and visitor temperature lot. PPE supplies are readily available to staff, and an additional 30-day supply of PPE was observed stored in the garage. Sufficient paper, cleaning, and disinfecting supplies were observed. LPA Observed staff wear a face covering. LPA observed required postings throughout the facility. All medications were secured in a cabinet in the den and inaccessible to residents. LPA observed medications in their original packaging. LPA reviewed the MARs and matched them to the client medications. LPA reviewed all client files and found they contained the required documents. LPA reviewed staff file and found they contained the required documents, training, and certification. LPA reviewed Resident’s P&I log. LPA reviewed the Surety bond for $1,000 through S. Philips Surety and expires on 03/13/25. No deficiencies were cited.

An exit interview was conducted, and a copy of this report was provided to Administrator Allen D Hawkins.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

LIC809 (FAS) - (06/04)

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