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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601235
Report Date: 05/17/2022
Date Signed: 05/17/2022 01:56:34 PM

Document Has Been Signed on 05/17/2022 01:56 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:DOLAN HOMEFACILITY NUMBER:
198601235
ADMINISTRATOR:GURITH TORRES MILIANFACILITY TYPE:
735
ADDRESS:12522 DOLAN AVETELEPHONE:
(562) 923-1172
CITY:DOWNEYSTATE: CAZIP CODE:
90242
CAPACITY: 4CENSUS: 3DATE:
05/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Beatriz Milian-Torres - House ManagerTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility with focus on the infection control domain, medication and food review. LPA Mora met with House Manager Beatriz Milian-Torres and explained the reason for the visit. The facility is licensed to serve 4 developmentally disabled and ambulatory only adults ages 18-59. There are currently 3 ambulatory level 3 clients serviced by South Central Los Angeles Regional Center.

The facility is in a residential area and it is a two story family home. Only the first floor is licensed and it includes: 2 client bedrooms, 3 bathrooms, office room, dining room, kitchen, living room, family room, 2 outdoor shaded patio areas, 3 locked backyard sheds, a detached garage/warehouse and an outdoor laundry area. There is a pool in the backyard with a net covering and outdoor jacuzzi with a locked cover.

LPA Mora conducted the tour with Beatriz Milian-Torres and observed the following: sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were observed in the kitchen. Sharps were observed locked in the medication closet. Chemical and cleaning solutions are kept locked in one of the backyard sheds. The First Aid kit is kept in a hallway closet and it is fully stocked with all required items including a current manual. Clean towels and extra clean linen were observed in a hallway closet. Dining and living room have sufficient lighting and sitting area. Medications are kept locked in the medication closet in the hallway. Client and staff files are kept in the staff office. All bedrooms have all required furniture, lighting, and bedding. All bathrooms were observed clean and in good repair with shower mats. The water temperature was tested in all bathrooms and measured between 110.4 degrees F and 115.2 degrees F, which is within the required 105-120 degrees F. There is one fire extinguisher observed in the dining room and it is fully charged. Smoke detectors were observed throughout the facility and in each room and were operable during the visit. There is a carbon monoxide near the kitchen and it was operable during the visit. The front yard and backyard are clean. There are shaded areas with seating in the backyard. Passageways and exits are free of obstruction. (CONTINUED TO LIC 809C)
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2022
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: DOLAN HOME
FACILITY NUMBER: 198601235
VISIT DATE: 05/17/2022
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LPA reviewed medication for 3 clients. Medications are documented properly and given as prescribed. LPA reviewed files for 3 clients and 3 staff. There were no issues found with the files. LPA observed administrator certificate for Gurith Milian - 6009346735 with an expiration date of 09/29/2023.

Facility has 30 days supplies of Personal Protective Equipment in the hallway closet and in one of the backyard sheds. Facility is following COVID-19 recommendations regarding screening visitors, staff, and clients. Covid-19 prevention signs are posted throughout the facility and hand-washing signs were observed in the bathrooms. Sufficient hand soap, hand sanitizer, and paper towels were observed.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.

SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
LIC809 (FAS) - (06/04)
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