198601990-2-14-2025-28-AS-LDLN-DDVSBH-20250214124358

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601990
Report Date: 02/14/2025
Date Signed: 02/14/2025 12:44:14 PM

Document Has Been Signed on 02/14/2025 12:44 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	DUNGARVIN CALIFORNIA - NORWALK		FACILITY NUMBER:	198601990
ADMINISTRATOR/ DIRECTOR:	CHRISTINE GRANT		FACILITY TYPE:	775
ADDRESS:	11005 FIRESTONE BLVD UNIT 117		TELEPHONE:	(562) 623-9800
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY: 30		CENSUS: 19	DATE:	02/14/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Ariel Samuela Program Director		TIME VISIT/ INSPECTION COMPLETED:	12:50 PM

NARRATIVE

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License Program Analysts (LPAs) Luis De Leon, Mayra Cota, and Blanca Gonzalez along with Fernando Fierros (LPM) conducted an unannounced annual required visit. LPA’s met with Program Director Ariel Elizarraras Samuela and Juan Zepeda, Area Director. The purpose of today’s visit was explained to facility personnel met during this visit. Facility is licensed to serve thirty (30) adults, of which ten (10) adults may be non-ambulatory.

The LPAs use the Compliance & Regulatory Enforcement Tool (CARE) during today’s inspection. The visit consisted as follows:

REVIEW OF FILES	FACILITY PHYSICAL PLANT
· Client Admission Agreements · Resident & Staff files · Staff fingerprint clearance · Staff First Aid Certificate · Consumer IPPs · Training Logs	· Three (3) offices · Activity room · Library and computer room · Emergency supply Room · Fitness and Spa Room/Quiet Room · Music, Game, and art Rooms · Kitchen, laundry, and janitor rooms · Four (4) restrooms

LPAs reviewed five (5) staff files and five (5) client files. Interviews were conducted with staff and clients.

Report continues on page LIC-809C

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Luis DeLeon
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2025

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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Document Has Been Signed on 02/14/2025 12:44 PM - It Cannot Be Edited

Created By: Luis DeLeon On 02/14/2025 at 11:58 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: DUNGARVIN CALIFORNIA - NORWALK	FACILITY NUMBER: 198601990
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

82087(a)(3)

Buildings and Grounds

(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (3) Disinfectants, cleaning solutions, poisons, and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observations, the licensee did not comply with the section cited above in storing desinfectants (Lysol), clorox wipes and paint in an accessible office to clients which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/14/2025
	Plan of Correction
1 2 3 4	Clear during visit, administrator removed medication to a secured location.

Type A

Section Cited

CCR

22075(l)(1)

(1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	At 10:05 AM, LPAs observed, the licensee did not comply with the section cited above in leaving staff medication (Ibuprofen 800 MG) accessible to clients in an unlocked cabinet in staff office space which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/14/2025
	Plan of Correction
1 2 3 4	Clear during visit, administrator removed medication to a secured location.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Fernando Fierros

LICENSING EVALUATOR NAME:

Luis DeLeon

LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2025

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: DUNGARVIN CALIFORNIA - NORWALK	FACILITY NUMBER: 198601990
	VISIT DATE: 02/14/2025

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Observations during facility tour:

· Clients bring own meal, but facility offers snacks throughout the day. There was emergency food supply available.
· Adequate lightning and comfortable room temperatures were observed.
· Required postings were observed at facility.
· Sharps are locked in kitchen and art room cabinets were observed to be locked.
· Hardwired smoke detectors and carbon monoxide were observed and are interconnected throughout the facility. Four (4) fire extinguishers were observed and are fully charged with last service date was on 1/22/25.
· Two (2) First Aid Kits were observed fully stocked.
· Last fire drill was conducted on 1/6/25. Last earthquake drill was conducted on 12/10/24.
· The water temperature was tested and measured for all bathrooms, kitchen, and meeting room. The temperature on all stations were found in compliance with Title 22 regulations between 105º and 120º F degrees. Restrooms were stocked and cleaned. Toilets were functioning properly.
· Sanitation stations were observed throughout facility with enough PPE available for clients.
· Pathways and hallways were clear of obstructions.
· Chemicals, cleaning supplies, and medications were observed in an office which is accessible to clients.

Two (2) deficiencies have been cited on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided to program director Ariel Elizarraras Samuela.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Luis DeLeon
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2025

LIC809 (FAS) - (06/04)

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