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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601841
Report Date: 12/09/2021
Date Signed: 12/09/2021 04:06:01 PM

Document Has Been Signed on 12/09/2021 04:06 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:
12/09/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Christopher YoungTIME COMPLETED:
04:30 PM
NARRATIVE
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On 12/9/2021 at 9:10 a.m. Licensing Program Analyst (LPA) , Nina Galarza conducted an unannounced Case Management visit. Purpose of the visit was to address deficiencies observed during an inspection. The purpose of this visit was explained to Program Manager, Christopher Young. Provider Relations Specialist, Juan Burmudez from Harbor Regional Center was also present during this visit.

During the visit LPA observed:
  • Staff#1(S1) and Staff#2 (S2) at the facility, but not associated to the facility.
  • Window in client bedroom #1 in disrepair
  • Front door chime, medication door chime, and sliding door chime in client bedroom #3 not turned on
  • Dresser in client bedroom #3 in disrepair
  • An out door umbrella in disrepair
  • Patio chairs in backyard area in disrepair
  • Side wooden gate in disrepair
  • Living Room Couch in disrepair
  • Trashcans filled with dirt blocking walkway in back yard
  • Mop buckets blocking walkway in backyard
  • A mop, broom and water hose blocking walkway in backyard


Civil Penalty in the amount of $1000 is being assessed today.

Deficiencies cited under California Code of Regulations, refer 809-D

Exit Interview conducted, copy of report and appeal rights provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nina Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2021
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 3
Document Has Been Signed on 12/09/2021 04:06 PM - It Cannot Be Edited


Created By: Nina Galarza On 12/09/2021 at 02:19 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: DEVLIN FACILITY
FACILITY NUMBER: 198601841

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2021
Section Cited
CCR
80087(c)

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80087 Buildings and Grounds (c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
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Administrator will remove items and send picture proof of walkway in backyard is free from obstruction to LPA Nina Galarza via email by POC date
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LPA observed Trashcans filled with dirt blocking walkway in back yard.Mop buckets blocking walkway in backyard. A mop, broom and water hose blocking walkway in backyard
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Type B
12/23/2021
Section Cited
CCR80087(a)

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80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
This requirement is met as evidenced by:
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Administrator will provide picture proof of all disrepaired items replaced or repaired via email to LPA Nina Galarza by POC date
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LPA observed Window in client bedroom #1 in disrepair, Front door chime, medication door chime, sliding door chime in client bedroom #3 not turned on.Dresser in client bedroom #3 in disrepair. An out door umbrella in disrepair. Patio chairs in backyard area disrepair.Side wooden gate in disrepair.
Living Room Couch in disrepair
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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:Wei Siew Ho
LICENSING EVALUATOR NAME:Nina Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2021


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/09/2021 04:06 PM - It Cannot Be Edited


Created By: Nina Galarza On 12/09/2021 at 02:28 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: DEVLIN FACILITY
FACILITY NUMBER: 198601841

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2021
Section Cited
CCR
80019(e)(2)

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80019 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:(2) Request a transfer of a criminal record clearance.. This requirement is not met as evidenced by:
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Administrator will associate all individuals who work at the facility on Guardian and submit picture proof via email to LPA Nina Galarza by POC date
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LPA observed Staff#1(S1) and Staff#2 (S2) at the facility, but not associated to the facility.
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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:Wei Siew Ho
LICENSING EVALUATOR NAME:Nina Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2021


LIC809 (FAS) - (06/04)
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