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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601350
Report Date: 11/08/2024
Date Signed: 11/08/2024 12:50:27 PM

Document Has Been Signed on 11/08/2024 12:50 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:DIXON HOMEFACILITY NUMBER:
198601350
ADMINISTRATOR/
DIRECTOR:		DENISE BRENKLINFACILITY TYPE:
735
ADDRESS:4333 W 58TH PLACETELEPHONE:
(323) 294-1942
CITY:LOS ANGELESSTATE: CAZIP CODE:
90043
CAPACITY: 4CENSUS: 2DATE:
11/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Denise Brenklin/AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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On 11/8/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Denise Brenklin/Administrator and explained the purpose of today’s visit. The facility is licensed to operate for (4) (developmentally disabled or Mentally Ill) adults ages 18 through 59. Approved for (2) ambulatory and (2) non-ambulatory. Currently, the home has (2) clients. The clients are from South Central Los Angeles Regional Center. (0) Restricted Health Care Conditions, and (0) utilizes postural support or protective devices. Staff to client ratio is (1:2).

The facility is a single-story structure located in a residential neighborhood. It consists of (2) bedrooms, (2) bathrooms, a living room, kitchen, dining room, laundry area, indoor and outdoor activity area, and an attached garage.

During the inspection, LPA Iniguez and the Administrator toured both the inside and outside of the facility, inspecting a total of (2) bedrooms and (2) bathrooms. LPA found that the mattresses and box springs were in good condition, there was adequate lighting, and plenty of dresser and closet space. The facility was observed to be clean, sanitary, and in good repair. Additionally, bed linens, comforters, and bath towels were adequately stocked during the visit. The bathrooms were found to be in compliance with Title 22 regulations, the toilets and water faucets worked properly.

The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2024
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: DIXON HOME
FACILITY NUMBER: 198601350
VISIT DATE: 11/08/2024
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The shower was free of mold and mildew, and there was adequate lighting and sufficient toiletries accessible to clients. The water temperature measured between 105°F and 120°F, with the kitchen at 118.4°F and Bathroom #1 at 116.4°F. During the visit, LPA found that the perishable and non-perishable food supply was adequately stocked. The carbon monoxide/smoke detector combo was operational, and fire extinguishers were fully charged. Toxins and knives were securely locked away from clients. Medications were centrally stored and properly locked, ensuring safety. The first aid kit was also found to be fully stocked, ready for any emergency.

LPA conducted a records review of (2) client and (2) staff records. LPA reviewed (1) Client Medication Administration Records (MAR) and did not observe any discrepancies. The facility disaster plan was current and in compliance with Title 22 at the time of the visit.

The last facility disaster drill was on 10/4/24. Facility licensee fees are current.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below:

-See D page(s) for details.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. *


An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Denise Brenklin/Administrator.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/08/2024 12:50 PM - It Cannot Be Edited


Created By: Alfonso Iniguez On 11/08/2024 at 12:16 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: DIXON HOME
FACILITY NUMBER: 198601350

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in not having an admissions agreement for one of the clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/25/2024
Plan of Correction
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Licensee will ensure all clients have an admissions agreement at all times. As plan of correction, licensee will sent copy of admissions agreement to LPA via email before POC due date.
Type B
Section Cited
CCR
80070(b)(14)
Client Records
(b) Each record must contain information including, but not limited to, the following: (14) An account of the client's cash resources, personal property, and valuables entrusted as specified in Section 80026.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in not having an inventory list for one of the clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/25/2024
Plan of Correction
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Licensee will ensure all clients have an inventory list at all times. As plan of correction, licensee will sent copy of inventory list to LPA via email before POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Eva M Alvarez
LICENSING EVALUATOR NAME:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2024


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