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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601990
Report Date: 12/30/2025
Date Signed: 12/30/2025 05:19:51 PM

Document Has Been Signed on 12/30/2025 05:19 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 - NORWALKFACILITY NUMBER:
198601990
ADMINISTRATOR/
DIRECTOR:		CHRISTINE GRANTFACILITY TYPE:
775
ADDRESS:11005 FIRESTONE BLVD UNIT 117TELEPHONE:
(562) 623-9800
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 30CENSUS: 30DATE:
12/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:42 PM
MET WITH:Area Coordinator- Juan ZepedaTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst, (LPA), Elena Mallett conducted an unannounced Annual Visit and met with Area Coordinator, Juan Zepeda. The purpose of the visit was explained.
The Day Program is licensed to serve 30 Developmentally Disabled Adults of which 10 may be non-ambulatory. The facility is located in a commercial center and consists of a music room, a craft room,a gym room, spa room, library room, ,tech room,garden room, a teaching kitchen, entry room, 3 staff/ conference rooms and 4 bathrooms. There is no outdoor activity area. The facility is sanitary and all hallways and common areas were observed to be free of debris and obstruction.

The CARE Tool was utilized during this visit. Due to time constraints not all Domains were able to be completed. LPA will return on a later date to finish the remainder of the Domains in the Tool.
Infection Control: Facility maintains the required Infection Control Plan. Staff utilize proper cleaning and hand hygiene.

Physical Plant & Environment Safety: LPA toured facility. The facility is well maintained and halls and passage ways free from obstruction and debris. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked cabinets and are inaccessible to clients. Smoke detectors and carbon monoxide detectors are operable and in compliance.LPA was provided with Rapid Fire Annual Fire Alarm and Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2025
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 12/30/2025 05:19 PM - It Cannot Be Edited


Created By: Elena Mallett On 12/30/2025 at 04:12 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
, 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: 12/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 2 out of 4 restroom sinks did not deliver water within Title 22 Regulations (restroom #2 121.6 F and restroom #4 66.1 F) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/31/2025
Plan of Correction
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BY POC due date Licensee will email a picture of water in restrooms measuring within in Title 22 regulations. Hot water was lowered in restroom #2 and POC cleared on day of visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Elena Mallett
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2025


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: 12/30/2025
NARRATIVE
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Signal Inspection report dated 07/29/25. There are 3 fully charged fire extinguishers present. Client and Staff files are kept locked in rooms. Water in 2 out of 4 bathrooms did not measure within Title 22 requirements. See 809-D. All rooms were observed to be well lit and serving their designed purpose. Snacks are prepared in a teaching kitchen. Client have a storage area to bring their own snacks and belongings if they choose. Appliances were observed to be operable for food storage and preparation. Drinking water is available through the refrigerator.

Operational Requirements: Staff have proper training to meet the needs of the clients in care. Regional Center ratios are observed for supervision of clients.

Staffing&Personnel Records-Training: There appears to be sufficient staffing at all times. LPA reviewed 5 staff files during today’s visit.Files reviewed contained the following: Criminal Background Clearance, Health screening, current First-Aid/CPR/MANDTI and proof of ongoing training. There were no issues observed. Area Coordinator Zepeda stated documents for Program Director Change request would be sent to Licensing next week for Ariel Samuela.

Due to time constraints LPA will return to facility for Annual Continuation visit at another date. A deficiency per Title 22 Regulations was cited today. An exit interview with Area Coordinator Juan Zepeda was conducted and a copy of this Licensing Report along with Appeal Rights was provided.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025
LIC809 (FAS) - (06/04)
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