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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601350
Report Date: 11/09/2021
Date Signed: 11/09/2021 02:21:26 PM

Document Has Been Signed on 11/09/2021 02:21 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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:DIXON HOMEFACILITY NUMBER:
198601350
ADMINISTRATOR:DENISE BRENKLINFACILITY TYPE:
735
ADDRESS:4333 W 58TH PLACETELEPHONE:
(323) 294-1942
CITY:LOS ANGELESSTATE: CAZIP CODE:
90043
CAPACITY: 4CENSUS: 2DATE:
11/09/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:13 PM
MET WITH:Pamela DixonTIME COMPLETED:
02:29 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ulysses Coronel conducted a Case Management - Deficiencies to cite deficiencies on violations observed during the investigation conducted on a complaint with complaint control number 11-AS-20210322093203. LPA was met by staff Raven Scott and Administrator Pamela Dixon, LPA was allowed entry into the facility.

During todays visit LPA observed that a shattered light bulb installed in an uncovered lamp was placed on top of a dresser inside bedroom number 2 and was accessible to clients in care.

Title 22 Division 6 Chapter 1 Article 7 is being cited please see LIC809D.

An exit interview was conducted and a plan of correction was developed. A copy of this report and appeals rights were provided to Pamela Dixon.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2021
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
Document Has Been Signed on 11/09/2021 02:21 PM - It Cannot Be Edited


Created By: Ulysses Coronel On 11/09/2021 at 12:19 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: DIXON HOME
FACILITY NUMBER: 198601350

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/16/2021
Section Cited
CCR
80087(g)(1)

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80087(g)(1) Buildings and Grounds. Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. Storage areas for poisons, and firearms and other dangerous weapons shall be locked. This requirement was not met as evidenced by:
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The licensee agreed create a plan of correctrion to address Title 22 regulation 80087(g)(1) Buildings and Grounds., which includes a review of the regulatiion with staff. Proof of corrections will be due by POC due date.
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Based on LPA observation and interviews conducted, the licensee faied to ensure that items that could pose a danger if readily available to clients were stored inaccessible to clients. A shattered lightbulb was accessible to clients in bedroom 2 which poses a potential health and safety risk to clients in care.
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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:Janae Hammond
LICENSING EVALUATOR NAME:Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2021


LIC809 (FAS) - (06/04)
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