198601841-5-25-2024-28-AS-THEA-D5LQK7-20240525121352

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601841
Report Date: 05/25/2024
Date Signed: 05/25/2024 12:13:58 PM

Document Has Been Signed on 05/25/2024 12:13 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
GREATER LA AC/SC, 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:	05/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:39 AM
MET WITH:	Monique Capers - DSP		TIME VISIT/ INSPECTION COMPLETED:	12:30 PM

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Licensing Program Analyst (LPA) Tena Herrera conducted the required unannounced annual inspection. LPA met with Monique Capers (Direct Support Staff-DSP) and Wendy Julks (DSP) and explained the reason for the visit. Administrator Ashliee Jackson later arrived at 11:30am to assist with the visit and provide staff files. The facility is licensed to serve (3) Non-Ambulatory Adults, ages 18 through 59. Facility currently has 1 Ambulatory and 2 Non- Ambulatory clients serviced by Harbor Regional Center.

The facility is a single-story home located in a residential area in Lakewood, Ca. A tour of the facility includes: living room, dining area, kitchen, 3 client bedrooms, 2 client bathrooms (1 is a private bath in master room), attached garage (with laundry), front yard and back yard.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility.
Physical Plant & Environment Safety: LPA toured facility, clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested in the client bathrooms and was within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked cabinet and are inaccessible to clients. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged.
Operational Requirements: Staff have proper training to meet the needs of the clients in care. Facility has an activity area furnished for outdoor use. Last fire/earthquake drill was conducted on 4/4/24.
(continued on LIC809-C)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2024

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: DEVLIN FACILITY	FACILITY NUMBER: 198601841
	VISIT DATE: 05/25/2024

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Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the clients in the case of an emergency.
Personnel Records-Training: Staff files are maintained in a secure location. LPA reviewed 4 staff files during today’s visit, files reviewed contained the following: Criminal Background Clearance, First-Aid/CPR/AED/CPI and sufficient on-going training. Facility has a Licensing clearance where if staff are associated to central facility they are cleared for all other Administrator Ashliee Jackson maintains a valid certificate that expires on 2/09/26.
Client Rights-Information: Facility provides telephone landline and internet for the clients. Client rights posters and reporting posters are displayed within the facility.
Client Records-Incident Reports: Client files are maintained in a secured locked cabinet and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. LPA reviewed 3 client files with no issues.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Staff designated to administer medication have the proper annual training on file. Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers. Incidental Medical & Dental: All training is documented in the facility personnel files. Staff performance is reviewed annually, and documentation is maintained in the personnel files.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Facility maintains documentation of the required emergency drills.
Emergency Intervention: Clients at this facility do not need the use of restraints or de-escalation techniques.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during todays.

Exit interview was held and a copy of the report was given to Administrator Ashliee Jackson

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2024

LIC809 (FAS) - (06/04)

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