<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601235
Report Date: 05/19/2024
Date Signed: 05/19/2024 11:06:04 AM

Document Has Been Signed on 05/19/2024 11:06 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:DOLAN HOMEFACILITY NUMBER:
198601235
ADMINISTRATOR/
DIRECTOR:		GURITH TORRES MILIANFACILITY TYPE:
735
ADDRESS:12522 DOLAN AVETELEPHONE:
(562) 923-1172
CITY:DOWNEYSTATE: CAZIP CODE:
90242
CAPACITY: 4CENSUS: 4DATE:
05/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:House Manager Beatriz Milian-TorresTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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 Analysts (LPAs) Jose Villalobos conducted the unannounced Annual Inspection visit using the Compliance And Regulatory Enforcement (CARE) Tool. LPA met with Staff Beatriz Milian-Torres and the purpose of the visit was discussed. The following tool domains were completed:

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 and Environmental Safety: The facility is licensed to serve 4 developmentally disabled and ambulatory only adults ages 18-59. There are currently 4 ambulatory clients serviced by South Central Los Angeles Regional Center. 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. The facility was inspected during the physical plant tour. No passageways or paths were obstructed. Water temperature in bathrooms tested and observed within title 22 regulations. The knives and sharp items are stored in a locked closet. 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: Facility is operating within its approved clearance. Activities Calendar observed

Staffing: The facility has a sufficient amount of staff per shift in the facility. LPA reviewed staff roster to verify that there is a staff present during the Nightshift.

Continued on LIC 809-C
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2024
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 2
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: 05/19/2024
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
26
27
28
29
30
31
32
Personnel Records-Training: Personal records centrally stored. LPA inspected five (5) staff files. All staff are background check cleared and associated with the facility. All the staff files have the required Title 22 documents. The administrators certificate is currently active. All staff have current first aid and CPR

Client's Right - Information: No client in the facility required any postural support at the present time. Required postings observed. Personal Rights postings observed

Food Service: Supply of Non perishables and perishables was observed. Food supply was adequately stored. There is a second refrigerator on site with additional food stored. Pesticides and other toxic substances were not stored with the food supply. Kitchen area was clean. Food menu was observed.

Client Records/Incident Reports: Client files are centrally stored. LPA reviewed four (4) client files. Client files are up to date and have required documents.

Health Related Services: Medication is centrally stored and locked making them inaccessible to clients in care. LPA reviewed two (2) Client Medications. (2) clients are out with family and have the medications with them. LPA did not observe any medication mismanagement or errors in the documentation of medications.

Incidental Medical Services: No client in the facility has any restricted health condition plan. There are no clients in care with prohibited or restricted health conditions. First Aid kid observed and available when needed.

Disaster preparedness: The facility has an updated emergency disaster plan. Facility has client information readily available in case of emergencies. Last fire drill conducted was on 3/4/24 and it was completed as a Fire/Emergency Disaster drill.

Emergency Intervention: The facility are not using any restraints in the facility.

Per Title 22 Regulations, no deficiencies are being cited on todays visit.

Exit Interview conducted. A copy of the report was provided
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2