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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601841
Report Date: 05/24/2022
Date Signed: 05/24/2022 11:57:17 AM

Document Has Been Signed on 05/24/2022 11:57 AM - 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:
05/24/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Tranae Gatlin - DSP 2TIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Luis Mora conducted a case management visit after discovering a deficiency during a complaint investigation for control number: 28-AS-20220516115309. Client 1 (C1) has dementia and his physician report is outdated. A current physician report is needed for the complaint investigation.

The deficiency cited is documented on the LIC809D. Exit interview held and a copy of the report and appeal was provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2022
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 05/24/2022 11:57 AM - It Cannot Be Edited


Created By: Luis Mora On 05/24/2022 at 11:37 AM
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: 05/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2022
Section Cited
CCR
87705(c)(5)

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87705 - Care of Persons with Dementia(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(5) Each resident with dementia shall have an annual medical assessment...and a reappraisal done...
This requirement is not met as evidenced by:
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Licensee will schedule a physician appointment and provide the LPA with a current physician report.
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C1's physician report is dated 04/26/2021.
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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:Stefanie Coronel
LICENSING EVALUATOR NAME:Luis Mora
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022


LIC809 (FAS) - (06/04)
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