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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603019
Report Date: 11/12/2024
Date Signed: 11/12/2024 04:21:13 PM

Document Has Been Signed on 11/12/2024 04:21 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:DOWNEY HOME IIFACILITY NUMBER:
198603019
ADMINISTRATOR/
DIRECTOR:		MILIAN, FAHIRFACILITY TYPE:
735
ADDRESS:9107 MARGARET STTELEPHONE:
(562) 682-2417
CITY:DOWNEYSTATE: CAZIP CODE:
90241
CAPACITY: 4CENSUS: 4DATE:
11/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:05 PM
MET WITH:Shawn Lopez - House ManagerTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with both Shawn Lopez and Maria "Maricela" Rodriguez (House Manager's) and explained the purpose for today’s visit. The facility is licensed to serve (4) ambulatory clients ages 18-59.

The facility is a single-story home located in a residential area in Downey, Ca. A tour of the facility includes: 2 living rooms, dining area, 2 kitchens, laundry area, office area, 2 bathrooms (1 is designated for staff), 3 client bedrooms (one of which is a shared bedroom), storage closet, detached garage, and outdoor shaded activity area.

LPA utilized the Compliance & Regulatory Enforcement (CARE) tools for the visit and observed the following:


Infection Control: Facility has the required Infection Control Plan.
Physical Plant & Environment Safety: LPA toured facility, clients’ bedrooms had closet/drawer space to accommodate each client comfortably. The outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked area. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged.
Operational Requirements/Staffing: Staff have proper training to meet the needs of the clients in care.
There appears to be sufficient staffing at all times in the facility.
Personnel Records-Training: Staff files are maintained in a secure location. LPA reviewed 5 staff files during today’s visit, files reviewed contained the following: Criminal Background Clearance, First-Aid/CPR/AED and sufficient on-going training. Gurith Milian maintains a valid certificate that expires on 9/29/2025.
(Continued on LIC809-C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2024
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: DOWNEY HOME II
FACILITY NUMBER: 198603019
VISIT DATE: 11/12/2024
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Client Rights-Information: Facility provides telephone landline and internet for the clients. Client rights posters and reporting posters are displayed within the facility.
Client Records-Incident Reports: Client files are maintained in a secured locked cabinet and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. LPA reviewed 4 client files with no issues.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service & Incidental Medical & Dental: Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers. LPA reviewed 4 clients medications with no issues. Staff designated to administer medication have the proper annual training on file.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Facility maintains documentation of the required emergency drills with the last drill completed on 9/25/24.
Emergency Intervention: Clients at this facility do not need the use of restraints or de-escalation techniques.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during todays visit.

Exit interview was held and a copy of the report will be emailed to Maricela Rodriguez and Shawn Lopez.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024
LIC809 (FAS) - (06/04)
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