<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601864
Report Date: 08/22/2025
Date Signed: 08/22/2025 03:36:04 PM

Document Has Been Signed on 08/22/2025 03:36 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:DUNGARVIN CALIFORNIA - LONG BEACHFACILITY NUMBER:
198601864
ADMINISTRATOR/
DIRECTOR:		JUAN ZEPEDAFACILITY TYPE:
775
ADDRESS:2534 E SOUTH STTELEPHONE:
(562) 408-4801
CITY:LONG BEACHSTATE: CAZIP CODE:
90805
CAPACITY: 30CENSUS: 46DATE:
08/22/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:11 PM
MET WITH:Area Director Juan ZepedaTIME VISIT/
INSPECTION COMPLETED:
03:38 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
On 08/22/25 The Department conducted a subsequent case management visit in response to the Special Incident Report submitted to CCLD about an incident occurring on 08/21/23. The department met with the Area Director Juan Zepeda as the purpose of the visit was explained.

The investigation consisted of the following: On 08/22/23 The Department conducted an unannounced health and safety check to follow up on an incident that occurred on 08/21/23. On 08/22/25 The department obtained copies of the following for client #1-2 (C1-C2); physicians report, face sheet, IPP, behavior plan, incident reports for the for the last 6 months, daily notes, client roster, staff roster, and staff training records. On 09/11/23 The Department conducted interviews with client #1-2 (C1-C2), and witness #1-2 (W1-W2). On 09/07/23 The Department obtained a copy of Memorial Care Long Beach Medical center medical records for C2. On 10/21/23 The Department obtained a copy of the Long Beach Fire Department report. On 10/31/23 The Department obtained a copy of the Long Beach Police Department report. On 11/08/23 The Department conducted interviews with staff #1-9 (S1-S9), and on 11/20/23 The Department conducted interview with witness #3 (W3).

The investigation revealed the following: On 09/11/23 The Department conducted interviews with C1-C2, 2 of the 2 clients interviewed confirmed the incident that occurred on 08/21/23. On 09/11/23 The Department conducted interviews with W1-W2, 1 of 2 witnesses interviewed reported having no concerns prior to incident occurred on 08/21/23. 1 of the 2 witnesses interviewed reported that Dungarvin California Long Beach staff are aware that C1 was not to have access to sharp objects. On 11/08/23 and 11/14/23 The Department conducted interviews with S1-S9. During the interview with S1, S1 reported C1.

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Lizeth Villegas
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2025
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 5
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: DUNGARVIN CALIFORNIA - LONG BEACH
FACILITY NUMBER: 198601864
VISIT DATE: 08/22/2025
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
was assigned to S1’s group when the incident occurred. Per S1 a knife was placed in the sink after S1 had used it, S1 then asked C1 to place a strainer in the sink while S1 engaged with a different client in the group. S1 continued to report that from the corner of S1’s eye, S1 saw C1 walking towards the spa room and asked where C1 was going. S1 states when C1’s name was called C1 began to walk faster, S1 indicated S1 did not see C1 holding the knife. S1 proceeded to follow C1 but when S1arrived at the spa room, C1 had already stabbed C2. S1 indicated approaching C1 and leading C1 to the corner of the kitchen. 6 of 9 staff interviewed reported being on shift when the incident occurred but did not observe the incident taking place. 1 of 9 staff reported they were not on shift the day the incident occurred.

The Department conducted a review of the Long Beach Fire department. Per report, C2 was found sitting on a chair with a stabbing wound on the right shoulder. C2 was noted to have been stabbed with an approximately eight-inch knife. Review of the knife indicated the knife may have possibly entered up to four inches into the right shoulder of C2, C2 had a small one-inch visible laceration and no other complaints of pain or injuries. C2 was transported to Memorial Care Long Beach Medical Center for further medical evaluation. The Department reviewed the Memorial Care Long Beach Medical center medical records for C2, records indicate that on 08/21/2023, at approximately 1431 hours, C2 arrived at the Long Beach Memorial Emergency Room via paramedic ambulance for a stab wound to the right shoulder. Per emergency medical services (EMS), C2 was stabbed with an 8-inch blade and there was an open wound with no active bleeding. The laceration was estimated to be 1-2 inches. X-ray imaging of right shoulder showed no acute fractures nor radiopaque foreign bodies. The wound was explored, and no foreign body was found, and no critical structures were noted to be involved. Three staples were used to repair the wound which was noted to be two centimeters in length. Subsequently, at 1621 hours, C2 was discharged. The Department conducted a review of the Long Beach Police Report, per police report Officer responded to the day center facility regarding a call reporting a client stabbed another client with a kitchen knife. Officers interviewed C1, C1 confirmed the incident on 08/21/23. During the interview with C1, C1 reported to officers that C1 walked into the kitchen area and picked up a knife, then walked to the spa area where C2 was and stabbed C2 once in the shoulder. C1 informed officers C1 felt remorse prior to C1 being transported to a mental health facility. Officer C2 had a one-inch laceration on his right shoulder and appeared in good spirits.

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Lizeth Villegas
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: DUNGARVIN CALIFORNIA - LONG BEACH
FACILITY NUMBER: 198601864
VISIT DATE: 08/22/2025
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
Based on the department’s observations, interviews, and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8) is cited on the attached LIC 809D. An immediate $500-dollar civil penalty was assessed.

Based on the department’s observations, interviews, and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8) is cited on the attached LIC 809D. An immediate $500-dollar civil penalty was assessed.

Exit interview conducted, appeal rights explained, and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Lizeth Villegas
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/22/2025 03:36 PM - It Cannot Be Edited


Created By: Lizeth Villegas On 08/22/2025 at 01:46 PM
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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: DUNGARVIN CALIFORNIA - LONG BEACH
FACILITY NUMBER: 198601864

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/05/2025
Section Cited
CCR
80072(a)(2)

1
2
3
4
5
6
7
80072 Personal Rights
Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: To be accorded safe, healthful and comfortable accommodation, furnishings and equipment to meet his/her needs.
1
2
3
4
5
6
7
Licensee shall review the section cited, and submit a plan to CCLD detailing how the facility will ensure clients persoanl rights are not violated, and how all clients in care will be accorded safe, healthful, and comfortable accommodations. To be sent by POC due date.
8
9
10
11
12
13
14
Based on records review and interviews the licensee did not comply with the section cited above as licensee did not ensure there are safety measures in place for all clients in care which poses a health and safety risk to clients in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Lizeth Villegas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5