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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601841
Report Date: 04/28/2022
Date Signed: 04/28/2022 01:38:29 PM

Document Has Been Signed on 04/28/2022 01:38 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:DEVLIN FACILITYFACILITY NUMBER:
198601841
ADMINISTRATOR:LA MARR, KEISHAFACILITY TYPE:
735
ADDRESS:20516 DEVLIN AVETELEPHONE:
(562) 278-2127
CITY:LAKEWOODSTATE: CAZIP CODE:
90715
CAPACITY: 3CENSUS: 3DATE:
04/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:44 AM
MET WITH:Vanessa Quirarte - AdministratorTIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility with focus on the infection control domain, medication and food review. LPA Mora met with Administrator Vanessa Quirarte and explained the reason for the visit. The facility is licensed to serve three non-ambulatory clients ages 18-59. The facility is in a residential area. A tour of the single-story facility included the kitchen, dining area, living room, 3 client bedrooms, 2 bathrooms, attached garage, front yard and backyard.

LPA Mora conducted the tour with Vanessa Quirarte and observed the following: sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were observed in the kitchen. Sharps were observed locked in the medication closet. Chemical and cleaning solutions are kept locked under the kitchen sink. The First Aid kit is kept locked in the medication closet and it is fully stocked with all required items including a current manual. Clean towels and extra clean linen were observed in each bedroom. Dining and living room have sufficient lighting and sitting area. Medications are kept locked in the medication closet in the hallway. Client files are kept in the medication closet. Staff files are kept in the garage. All bedrooms have all required furniture, lighting, and bedding. All bathrooms were observed with shower mats. One of the bathrooms have grab bars for the non-ambulatory client. The water temperature was tested in both bathrooms and measured at 114.4 degrees F and 107.8 degrees F, which is within the required 105-120 degrees F. Two fire extinguishers were observed in the kitchen and dining area and are fully charged. Smoke detectors combined with carbon monoxide were observed throughout the facility and in each room and were operable during the visit. The front yard and backyard are clean. There is a shaded area with seating in the backyard. No bodies of water were observed at the facility. Passageways and exits are free of obstruction.
LPA reviewed medication for all three clients. Medications are documented properly and given as prescribed. LPA reviewed files for all three clients and two staff. There were no issues found with the files. LPA observed administrator certificate for Vanessa Quirarte - 6061554735 with an expiration date of 12/05/2023.

(CONTINUED TO LIC 809C)
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: DEVLIN FACILITY
FACILITY NUMBER: 198601841
VISIT DATE: 04/28/2022
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Facility has 30 days supplies of Personal Protective Equipment in the garage. Facility is following COVID-19 recommendations regarding screening visitors, staff, and clients. Covid-19 prevention signs are posted throughout the facility and hand-washing signs were observed in the bathrooms. Sufficient hand soap, hand sanitizer, and paper towels were observed.


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.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC809 (FAS) - (06/04)
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