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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601990
Report Date: 02/09/2023
Date Signed: 02/09/2023 03:32:01 PM

Document Has Been Signed on 02/09/2023 03:32 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:DUNGARVIN CALIFORNIA - NORWALKFACILITY NUMBER:
198601990
ADMINISTRATOR:CHRISTINE GRANTFACILITY TYPE:
775
ADDRESS:11005 FIRESTONE BLVD UNIT 117TELEPHONE:
(562) 623-9800
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 30CENSUS: 13DATE:
02/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH: Day Services Manager Christine GrantTIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced Required 1 year inspection at the facility and met with Day Services Manager Christine Grant and explained the purpose for todays visit.

During today's visit LPA Calderon conducted a tour of the physical plant with Christine.

This program physical plant consist of the following:

Three Administrative Offices, Garden Room (Activity), Library, Exercise Room, Spa Room/Quiet Room, Music Room, Game Room, Emergency Supply Room, Janitor Room, Kitchen, Art Room, Computer Room and 4 restrooms (1 contains laundry machines). LPA observed the kitchen, client's bring their own snacks, the facility has food for cooking classes, and emergency food supplies available. Sharps are locked in kitchen and art room cabinets maintained locked. There is no medication administered to clients at this time. Chemicals locked in the Janitor Room. There are a total of 4 fully charged fire extinguishers throughout the facility. The fire alarm system and carbon monoxides are hardwired and connected to the Norwalk Fire Dept. The water temperature was tested and measured and falls between Title 22 Regulations. Activity Calendar posted, facility has 3 operable transportation vehicles. Restrooms stocked and cleaned, pathways and hallways clean and free of obstructions. LPA reviewed 5 staff folders. During the visit the Infection control domain was used. The facility had all Covid postings at the front entrance, bathrooms, and throughout the facility. Hand sanitizing gel and masks were located at the entry of each room. A Pre screening area with PPE supplies was observed upon entry into the facility, sufficient PPE for over 60 day. The facility mitigation plan was reviewed and approved on 03/22/2021. Trash bins with lids were observed, and one room is designated as an isolation room if a client has Covid-19 symptoms.

There were no deficiencies cited. An exit interview conducted with Day Services Manager Christine Grant a copy of this report was provided. .
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2023
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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