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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601168
Report Date: 11/18/2024
Date Signed: 11/21/2024 12:25:20 AM

Document Has Been Signed on 11/21/2024 12:25 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:DONZELL'S RESIDENTIAL FACILITY INC.FACILITY NUMBER:
198601168
ADMINISTRATOR/
DIRECTOR:		HICKS, STEPHANIEFACILITY TYPE:
735
ADDRESS:1812 WEST 134TH PLACETELEPHONE:
(310) 516-6668
CITY:GARDENASTATE: CAZIP CODE:
90247
CAPACITY: 6CENSUS: 2DATE:
11/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:49 PM
MET WITH:Stephanie Hicks, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On 11/18/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced required annual visit using the full CAREs Inspection Tool. LPA met with Administrator, Stephanie Hicks and explained the purpose of today’s visit. The facility is licensed to serve developmentally disabled residents ages 18 to 59 years old, cleared for six (6) ambulatory residents. Currently there are two (2) residents in care.

LPA reviewed all resident files and found they contained the required documents. LPA reviewed the Administrator’s file and found that it contained the required documents, training, and certification. LPA reviewed the surety bond and Liability Insurance.

LPA Felisa and Stephanie toured both inside and outside of the facility. The facility is a one-story structure located in a residential neighborhood. The facility consists of (3) bedrooms, (2) bathroom, living room, kitchen, dining area and patio. Facility maintains all required posting throughout the facility.

All bedrooms were toured. Bedroom 1 is occupied by both residents and contain the mandated furniture. Bedroom 2 is vacant and Bedroom 3 is used for staff. LPA observed all rooms to have the required furniture including a bed, nightstand, and chair(s). All beds had the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillow. LPA observed ample lighting in all the bedrooms.

LPA Shirley and Stephanie toured the kitchen and found it to be clean and sanitary. All appliances were in good working order. Knives, medications, first aid kits and manuals were locked and stored in the hallway closet inaccessible to the resident. The washer and dryer are in good working condition and are located in the garage. LPA observed a 3-day supply of perishable and a 7-day supply of nonperishable foods. The water temperature measured 115.9 degrees Fahrenheit.

Con'd on 809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
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: DONZELL'S RESIDENTIAL FACILITY INC.
FACILITY NUMBER: 198601168
VISIT DATE: 11/18/2024
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The (2) bathrooms are clean and operational. No firearms are stored at facility and no bodies of water present. This facility is in good repair.

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 located behind the front door. The backyard is clean and clear of obstructions and hazards, shaded patio area and there are no bodies of water present.

There were no deficiencies observed during this visit.


An exit interview was conducted, and a copy of this report was provided to the Administrator, Stephanie Hicks.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024
LIC809 (FAS) - (06/04)
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