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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601864
Report Date: 08/22/2023
Date Signed: 08/29/2023 08:22:14 AM

Document Has Been Signed on 08/29/2023 08:22 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:DUNGARVIN CALIFORNIA - LONG BEACHFACILITY NUMBER:
198601864
ADMINISTRATOR:GORDON DAMEONFACILITY TYPE:
775
ADDRESS:2534 E SOUTH STTELEPHONE:
(562) 408-4801
CITY:LONG BEACHSTATE: CAZIP CODE:
90805
CAPACITY: 30CENSUS: 40DATE:
08/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Day Services Manager Christine GrantTIME COMPLETED:
01:45 PM
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On 8/22/23, licensing program analyst (LPA) Lizeth Villegas conducted a case management visit in response to special incident report submitted to CCLD on 8/22/23 for incident occurring on 8/21/23; regarding client #1 assaulting client #2.

During today's visit LPA Villegas Conducted a health and safety visit which consisted of the following: LPA toured physical plant. obtained copies of client #1-#2 records (physicians report, facesheet, IPP, behavior plan, incident reports for the for the last 6 months, daily notes), client roster, staff roster, and staff training records.

Due to insufficient information available at this time, the above allegations need further follow up.

No immediate health and safety issues were observed.

Exit interview conducted with Day Services Manager Christine Grant, and a copy of this report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2023
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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