198601168-12-11-2023-11-AS-FSHY-CYESLQ-20231211125844

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601168
Report Date: 12/11/2023
Date Signed: 12/11/2023 12:58:51 PM

Document Has Been Signed on 12/11/2023 12:58 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	DONZELL'S RESIDENTIAL FACILITY INC.		FACILITY NUMBER:	198601168
ADMINISTRATOR:	HICKS, STEPHANIE		FACILITY TYPE:	735
ADDRESS:	1812 WEST 134TH PLACE		TELEPHONE:	(310) 516-6668
CITY:	GARDENA	STATE: CA	ZIP CODE:	90247
CAPACITY: 6		CENSUS: 2	DATE:	12/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:34 AM
MET WITH:	Stephanie Hicks		TIME COMPLETED:	01:00 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

Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced Annual inspection visit and infection control inspection to the above facility. LPA was met by Stephanie Hicks, Administrator the purpose of today’s visit was explained.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: 3 bedrooms, 2 bathrooms, family room/office, living room, kitchen, dining room, shaded area, laundry room an attached garage.

LPA Shirley and Stephanie walked through the kitchen and all appliances were in good working order. Knives were locked and stored and inaccessible to residents. A comfortable temperature is maintained in the facility. Ample supply of perishable and nonperishable food. The water temperature measured 119.6 degrees Fahrenheit. All bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly. The walk-in shower was free of mildew and mold.

LPA Shirley and Stephanie walked through all common areas. In the living room, kitchen, dining room there is ample seating and space for all residents. All rooms and walkways were clean, and clear of obstructions and hazards. All areas have ample lighting. All rooms, hallway, and living room have working smoke detectors. There is a charged fire extinguisher in the kitchen and hallway.

LPA Shirley and Stephanie toured the entire facility inside and out. Documents are posted as mandated. Bedrooms 1 is occupied by clients and contain the mandated furniture, bedroom 2 is vacant and bedroom 3 is used for staff. The (2) bathrooms are clean and operational. First aid kit is fully stocked with manual. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents. (1) Resident file along with medications are current. (1) Staff file is current. The facility is in good repair.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview conducted with Stephanie Hicks, Administrator and copy of report provided.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 1