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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602394
Report Date: 09/28/2022
Date Signed: 09/28/2022 02:10:54 PM

Document Has Been Signed on 09/28/2022 02:10 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:DOWNEY HOMEFACILITY NUMBER:
198602394
ADMINISTRATOR:MILIAN, GURITHFACILITY TYPE:
735
ADDRESS:11403 HORTON AVENUETELEPHONE:
(562) 682-2417
CITY:DOWNEYSTATE: CAZIP CODE:
90241
CAPACITY: 4CENSUS: 4DATE:
09/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Maria Rodriguez - House ManagerTIME COMPLETED:
02:25 PM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility with focus on the infection control domain, medication and food review. LPA Mora met with Maria Rodriguez (House Manager) and explained the reason for the visit. The facility is licensed to serve four ambulatory clients ages 18-59. Facility currently has 4 ambulatory clients serviced by South Central Los Angeles Regional Center.

The facility is in a residential area and it is a one story family home. A tour of the single-story facility included the office room, kitchen, dining area, 2 living rooms, laundry area, 1 storage room, 3 client bedrooms (1 shared bedroom), 2 client bathroom, 1 staff bathroom, front yard, backyard, and detached garage.

LPA Mora conducted the tour with Maria Rodriguez and observed the following: sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were observed in the kitchen. Sharps were observed locked in a box and kept in the pantry. Chemical and cleaning solutions are kept locked in a laundry cabinet. The First Aid kit is kept locked in the medication cabinet and it is fully stocked with all required items including a current manual. Clean towels and extra clean linen were observed in the storage room. Dining and living room have sufficient lighting and sitting area. Medications are kept locked in a hallway closet. Client and staff files are kept locked in the office room. All bedrooms have all required furniture, lighting, and bedding. The client bathrooms were observed with shower mats. The water temperature was tested in all bathrooms and measured at 106.7 degrees F, 105 degrees F, and 105.2 degrees F which are within the required 105-120 degrees F. A fire extinguisher was observed in the laundry area and it is fully charged. Smoke detectors and carbon monoxides were observed throughout the facility and were operable during the visit. The front yard and backyard are clean. There is a shaded area with seating in the backyard. No bodies of water were observed at the facility. Passageways and exits are free of obstruction.

(CONTINUED TO LIC 809C)
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: DOWNEY HOME
FACILITY NUMBER: 198602394
VISIT DATE: 09/28/2022
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LPA reviewed medication for 4 clients and observed that medications are documented properly and given as prescribed. LPA reviewed files for all 4 clients and 4 staff. No issues were found with the files. LPA observed administrator certificate for Gurith Milian – 6009346735 with an expiration date of 09/29/2023.

Facility has 30 days supplies of Personal Protective Equipment in the storage room. Facility is following COVID-19 recommendations regarding screening visitors, staff, and clients. Covid-19 prevention signs are posted throughout the facility and hand-washing signs were observed in the bathrooms. Sufficient hand soap, hand sanitizer, and paper towels were observed.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there was no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.

SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022
LIC809 (FAS) - (06/04)
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