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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601402
Report Date: 01/24/2023
Date Signed: 01/24/2023 03:52:34 PM

Document Has Been Signed on 01/24/2023 03:52 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:DE LEON HOMEFACILITY NUMBER:
198601402
ADMINISTRATOR:MAUREEN DELEONFACILITY TYPE:
735
ADDRESS:11503 FERINA STTELEPHONE:
(562) 900-2717
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 4CENSUS: 3DATE:
01/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Cassandra Brown, DSPTIME COMPLETED:
03:55 PM
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Licensing Program Analysts (LPA) Galarza & Erik Zaragoza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPAs met with DSP staff Carol Amado and Cassandra Brown and explained the purpose of the visit. Administrator Rana Chapkhaneh was explained the purpose of the visit telephonically. There are currently three (3) level 4i ambulatory disabled clients ages of 18 through 59 serviced by Harbor Regional Center. The facility is a single story home located in a residential neighborhood. It consists of 4 client bedrooms, 2 bathrooms, kitchen, dining area, living room, outdoor patio, and attached garage. The last fire/emergency drill was conducted on 1/4/2023. Administrator certificate expires 5/4/2024.

OBSERVATIONS:
  • The interior and exterior physical plant was inspected. The facility is equipped with a fire pull alarm system. Smoke and carbon monoxide detectors were tested and operational.
  • COVID-19 Infection Control Practices and signs that promote hand washing, cough/sneeze etiquette, and physical distancing were observed in the entrance, common areas, hallways, bathrooms and client rooms. There is a screening station at the entrance of the facility to screen visitors.
  • Each client room is designated as a COVID-19 isolation room if needed.
  • A posted Emergency Disaster Plan was observed.
  • Centrally stored medications/30-day supply of medications were reviewed.
  • Staff were observed wearing mask. Clients do not wear masks due to disability exemption.
  • The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food.
  • Water temperature was within normal limits 105 degrees Fahrenheit (40.5 degrees C) and not more than 120 degrees Fahrenheit (48.8 degrees C).
  • Facility has an adequate 30-day+ supply of Personal Protective Equipment (PPEs).
  • The facility submitted a COVID-19 Mitigation Plan. An Infection Control Plan (ICP) has been submitted.
No deficiencies were cited.
Exit interview was conducted with staff Cassandra Brown. A copy of the report was issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2023
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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