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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601235
Report Date: 04/28/2023
Date Signed: 04/28/2023 03:41:41 PM

Document Has Been Signed on 04/28/2023 03:41 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
GREATER LA AC/SC, 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: 4DATE:
04/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:19 PM
MET WITH:Maria RodriguezTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Maria M Rodriguez (House Manager) 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 4 ambulatory level 4 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, 2 ½ bathrooms, office room, dining room, kitchen, living room, family room, 3 outdoor shaded patio areas, 4 locked backyard sheds, 1 locked shed that houses the washer and dryer a detached garage/warehouse and an outdoor laundry area. There is a pool in the backyard with a net covering/fencing and outdoor jacuzzi with a locked cover.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents’ medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan.
Physical Plant & Environment Safety: There are 2 client bedrooms, 2 ½ client bathrooms, living room, kitchen, dining area, family room and office. Clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The outdoor and passageways are free of obstruction. The outdoor side entrance/exit was locked and corrected during today’s visit. There are no security bars or weapons on the premises. Hygiene products are readily available and stored in clients restrooms.
(Continued on 809-C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2023
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: DOLAN HOME
FACILITY NUMBER: 198601235
VISIT DATE: 04/28/2023
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The hot water temperature was tested in kitchen and client bathrooms, they measured at 114.8 – 117.2 degrees F, these are within the required range of 105-120 degrees. The front yard is free of debris/hazards. All storage areas for cleaning solutions, toxins, and hazardous items are in a secured locked shed in the back yard and are inaccessible to clients. The knives and sharp items are stored in a locked closet in hallway. The last Fire/Emergency Drill was conducted on 3/4/2023. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguisher was observed in the dining area and is fully charged.
Operational Requirements: There are currently 4 ambulatory residents residing at the facility.
Resident Rights-Information: Residents personal rights poster is posted in the dining area near the kitchen and is clearly visible.
Resident Records-Incident Reports: Resident files are kept locked the staff office and has the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Staff designated to administer medication has the proper annual training on file. Medication is properly labeled and are centrally stored in a locked closet in the hallway and are in their original containers. During the visit today, LPA reviewed 2 residents' medication no issues were observed. One resident is away with family for the weekend and the other is currently not on medication.
Incidental Medical & Dental: All medications for clients are kept locked in a hallway closet and inaccessible to other clients.

LPA conducted 1 staff interviews and 0 resident interviews during todays visit.

Due to time restraints LPA Tena Herrera could not complete the annual inspection. LPA will return to finish remaining 4 domains at a later date.

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 to House Manager Maria Rodriguez.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023
LIC809 (FAS) - (06/04)
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