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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601235
Report Date: 05/08/2023
Date Signed: 05/08/2023 10:24:20 AM

Document Has Been Signed on 05/08/2023 10:24 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
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:
05/08/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:Maria RodriguezTIME COMPLETED:
09:35 AM
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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual continuation inspection. LPA arrived unannounced and met with Maria Rodriguez (House Manager) who assisted with the visit. The purpose for the visit was explained.

The facility is licensed to serve developmentally disabled adults ages 18 to 59 years old, ambulatory only.


LPA inspected the remaining four domains using the Compliance and Regulatory Enforcement (CARE) tools for which include the following:
Staffing, Personnel Records-Training, Disaster Preparedness, and Emergency Intervention

Staffing: There appears to be sufficient staffing at all times in the facility. Administrator Milian Torres Gurith certificate expires on 09-29-2023.
Personnel Records-Training: Staff has criminal record clearance. Staff has current first aid and CPR. Staff files are maintained at the facility located in a locked cabinet in the living room. Staff have current CPR/first aid training and sufficient on-going training.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.
Emergency Intervention: Residents at this facility do not have restraints nor do they require the use de-escalation techniques.

Today, LPA conducted 2 staff interviews. No client interviews were done today as clients were away at day program.

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 administrator Maria Rodriguez.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2023
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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