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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601841
Report Date: 04/29/2025
Date Signed: 04/29/2025 11:49:36 AM

Document Has Been Signed on 04/29/2025 11:49 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:DEVLIN FACILITYFACILITY NUMBER:
198601841
ADMINISTRATOR/
DIRECTOR:		TRANAE GATLINFACILITY TYPE:
735
ADDRESS:20516 DEVLIN AVETELEPHONE:
(562) 278-2127
CITY:LAKEWOODSTATE: CAZIP CODE:
90715
CAPACITY: 3CENSUS: 3DATE:
04/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:12 AM
MET WITH:Ann Hyde - Administrator TIME VISIT/
INSPECTION COMPLETED:
12:03 PM
NARRATIVE
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Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1-year visit using the full Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Ann Hyde, administrator for the facility, and explained the purpose of the visit. There are two (2) non-ambulatory and one (1) ambulatory clients residing in the facility.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.

Infection Control:

· Infection control practices were observed.



Physical Plant/Environment Safety:

· The facility is a single-story home located in a residential neighborhood that is licensed for a capacity of three (3) non-ambulatory clients between the ages of eighteen (18) through fifty-nine (59). It consists of three (3) client bedrooms, a kitchen, a living room, a dining room, an attached garage that contains extra supplies for the facility along with the washer and dryer, a backyard with shaded area, and two (2) client restrooms which had a hot water temperature reading of 105.5 and 113.6 Degrees Fahrenheit respectively Knives along with the chemicals and cleaning supplies are kept locked and inaccessible to clients.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2025
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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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)
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Document Has Been Signed on 04/29/2025 11:49 AM - It Cannot Be Edited


Created By: Erik Zaragoza On 04/29/2025 at 11:24 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: 04/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 3 out of 3 clients, because there was not a sufficient 7 day supply of non-perishable foods, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2025
Plan of Correction
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Administrator is to ensure that the the facility has the required 7-day supply of non-perishable foods at all times. Administrator is to purchase a 7-day supply of non-perishable foods for the facility and submit the receipt to LPA by the POC due date.
Type B
Section Cited
CCR
80070(a)
Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above in 1 out of 3 clients, because Client #1's MARs was not completely initialed for the month of April 2025, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/22/2025
Plan of Correction
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Administrator is to ensure that the MARs for all clients are initaled completely and thorougly at all times. Administrator is to submit to LPA the facilities written plan on how all medications for all clients are documented completely and accurately at all times by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Erik Zaragoza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2025


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: 04/29/2025
NARRATIVE
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·The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. There are no pools are or bodies of water accessible to the clients. Fire alarm system and carbon monoxide detectors are operational. The facility has two (2) fully charged fire extinguishers that are kept throughout the facility. Cleaning supplies and toxic substances are kept locked and inaccessible to clients.

Operational Requirements:

· Fire clearance was approved by LA County Fire Department for three (3) non-ambulatory clients between the ages of 18 – 59.


· Care and supervision to meet the clients’ needs was observed.

Staffing:

· A total of nine (9) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

· Administrator’s certificate expires on 10/10/2027.


· Five (5) staff files were reviewed for criminal background clearance and training.
· Personnel records have health/Tuberculosis (TB) screenings, certifications, and 1st Aid/CPR training.

Client Rights/Information:

· Physician orders were reviewed in client files.

Client Records/Incident Reports:

· Three (3) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, nutritional assessments, medication records, and Personal and Incidental (P & I) money were reviewed.


· One (1) client’s Medication Administration Records (MARs) were not completely initialed.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: 04/29/2025
NARRATIVE
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Food Service:

· The kitchen was inspected and the food preparation area, and storage areas were observed to be clean and sanitary. The two (2) day supply of perishable foods were observed in the kitchen, however the non-perishable food supply did not meet the seven (7) day requirement.



Health Related Services:

· Clients are assisted with self-administration of prescription and non-prescription medications.


· Three (3) centrally stored client medication records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions.

Incidental Medical and Dental:

· All clients have a Needs and Services Plan.


· Staff training was on file.

Disaster Preparedness, and Emergency Intervention:

· An Emergency Disaster Plan LIC610D is kept in the facility.


· The last documented disaster drill was documented on 4/24/2025.

Emergency Intervention:

· No manual restraints or seclusion are used with clients in care.



Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809D page. Exit interview held and a copy of the report along with appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
LIC809 (FAS) - (06/04)
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