198601841-3-5-2026-28-AS-EMAT-DRVS8K-20260305123916

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601841
Report Date: 03/05/2026
Date Signed: 03/05/2026 12:39:41 PM

Document Has Been Signed on 03/05/2026 12:39 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	DEVLIN FACILITY		FACILITY NUMBER:	198601841
ADMINISTRATOR/ DIRECTOR:	TRANAE GATLIN		FACILITY TYPE:	735
ADDRESS:	20516 DEVLIN AVE		TELEPHONE:	(562) 278-2127
CITY:	LAKEWOOD	STATE: CA	ZIP CODE:	90715
CAPACITY: 3		CENSUS: 3	DATE:	03/05/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Administrator- Renee Davenport		TIME VISIT/ INSPECTION COMPLETED:	12:40 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analysts (LPA) Elena Mallett arrived at the facility to conduct an unannounced Annual visit . LPA met with Staff Ryan and the purpose of the visit was explained. Administrator Renee Davenport joined the visit shortly after. The facility is licensed to serve three (3) non- ambulatory clients between the ages of 18 through 59.

The facility is a single-story home, located in a residential area of Lakewood that consists of a living room, dining area, a kitchen, three (3) client bedrooms, (2) bathrooms, an attached garage, a front yard and a backyard with a covered shaded area with seating.

LPA completed the visit using Compliance and Regulatory Enforcement Tools (CARE) . The following domains were completed during the visit

Infection Control: Infection Control Plan was reviewed by LPA. Facility follows title 22 regulations and is cleaning and disinfecting regularly. Staff has PPE and practices hand hygiene.

Physical Plant and Environmental Safety: Physical plant is clean and sanitary and the hallways and walkways are free from debris and obstruction. Hot water temperature measured within Title 22 regulations in both bathrooms. Facility has combination smoke and carbon monoxide detectors that were tested and operational. A fully charged fire extinguisher was present near the kitchen. Sharps and toxins are locked in cabinets. Client bedrooms required light and furnishings. Extra linens and blankets were observed. A mattress in one of the client’s bedrooms was observed to be stained. A deficiency was cited. See 809-D

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/05/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2026

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 4

California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

Page: 2 of 4

Document Has Been Signed on 03/05/2026 12:39 PM - It Cannot Be Edited

Created By: Elena Mallett On 03/05/2026 at 11:42 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: 03/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85088(c)(1)

Fixtures, Furniture, Equipment, and Supplies

(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (1) An individual bed, except that couples shall be allowed to share one double or larger sized bed, maintained in good repair, and equipped with good bed springs, a clean mattress and pillow(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 out of 3 client mattresses ( Bedroom #3) had a pillow case - sized light brown stain. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/19/2026
	Plan of Correction
1 2 3 4	By POC due date Licensee will send LPA a photo via email of a clean mattress for Bedroom #3

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:

	Elena Mallett
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/05/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2026

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: DEVLIN FACILITY	FACILITY NUMBER: 198601841
	VISIT DATE: 03/05/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Operational Requirements: Fire clearance approval was observed. Plan of operation was observed. Outdoor activity space with a furnished, shaded area was present. Activity supplies for clients were observed. A monthly activity calendar was provided. Clients attend Day Program and on the weekend staff take clients on outings such as community walks, to the mall and to religious services.

Personal Records - Training: Locked storage space for staff files was observed. 5 staff files were reviewed for Criminal Background Clearance, First Aid training, initial and ongoing trainings and health screening. No issues were observed. Administrator Davenport’s Administrator Certificate is current.

Client Records - Incident Reports: Locked Storage space for client files was observed. Clients’ files were reviewed for Emergency Face sheet, Physician’s Report with ambulatory status, Needs and Services plan, Admission Agreement and Personal Rights. Files for all three clients in care were reviewed and no issues were observed.

Client Rights - Information: Required postings were observed.

Food Service: Kitchen had functional appliances and was equipped to store and prepare food. 2 day perishable and 7 day non perishable food supply was observed. Food was kept separate from cleaners, toxins and poisons. A sample menu was provided.

Health Related Services: First Aid Kit and manual was observed. Facility utilizes a Medical Record Log. All three clients medicine logs were reviewed with no issues.

Disaster Preparedness: Facility has emergency disaster plan in place. Administrator will send updated Disaster Plan form to Licensing. Facility conducts quarterly disaster drills. The last drill was conducted on 02/13/26. Facility had several flashlights and emergency supply of water and food.

Facility handles clients' P&I money. Ledger was reviewed with no issues. Facility maintains a Surety Bond.

An exit interview was conducted with Administrator Renee Davenport. A deficiency was cited today Per 22 Regulations. A copy of this licensing report and Appeal Rights were provided to the Administrator.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/05/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2026

LIC809 (FAS) - (06/04)

Page: 4 of 4