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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603335
Report Date: 06/27/2023
Date Signed: 06/27/2023 12:45:01 PM

Document Has Been Signed on 06/27/2023 12:45 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:PDM - DEVLINFACILITY NUMBER:
198603335
ADMINISTRATOR:GONZALES, LUIS S.FACILITY TYPE:
735
ADDRESS:18104 DEVLIN AVE.TELEPHONE:
(562) 552-5579
CITY:ARTESIASTATE: CAZIP CODE:
90701
CAPACITY: 3CENSUS: 3DATE:
06/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Administrator Mary GonzalesTIME COMPLETED:
01:01 PM
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On 6/27/23 at 10:50 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual/Required inspection to PDM Delvin Home. Upon arrival LPA was greeted by Licensee/ Administrator Mary Gonzales and Administrator, Archimedes Lopez to assist with today's visit. This home is licensed to serve (3) Developmentally Disabled Adults, (3) non-Ambulatory and (3) maybe bedridden. The clients served are between the age of 18 through 59 with 1 hospice wavier, vendorized by Harbor Regional Center. There were (3) clients in care during the time of this visit. LPA was unable to interview the clients due to limited communication. The last emergency disaster/fire drill was conducted on 6/07/23. The Administrator Certificate expires on 8/12/2023 #600394735. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, reviewed (2) staff files, (3) client files, medications, and medication administration records for (3) clients and P&I.

This home contains 3 bedrooms, 1 bathroom, 1 staff bathroom, living room, kitchen, dining room, and an attached garage. LPA toured the physical plant with the Administrator. and observed all (3) client bedrooms, contained required furniture, lamps, dresser, chair, and closet space. The two bathrooms contain a working toilet, basin and water faucet, walk in shower with grab bar, shower chair, and skid matts. The temperature measured at 119.1*F-119.8*F. The smoke detectors were battery operated and tested and observed to be working properly. The carbon monoxide detector was located throughout the facility, tested, and functioning properly. There were (2) fire extinguishers located in kitchen and kitchen nook fully charged and up to date. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans with knives secured and locked in a cabinet. Underneath the kitchen sink cleaning agents and toxins are locked and secured. The pantry was well stocked with canned goods, pasta, and the food supply contained a sufficient supply with a two-day supply of perishables and a seven-day supply of non-perishables that met title 22 guidelines. Walls and floors, cabinets and counters were clean and sanitary throughout the home
(Report continued on LIC809C.)
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2023
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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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: PDM - DEVLIN
FACILITY NUMBER: 198603335
VISIT DATE: 06/27/2023
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The outdoor grounds were toured and inspected, and the patio was well maintained. The garage contained washer and dryer, storage, PPE supplies, and hygiene supplies.

The entry way, and kitchen nook contained notifications and postings: California Labor Laws, Emergency Disaster Plan, personal rights, facility license, business license, medical emergency information, let-us-know licensing contact information, consumer grievance, support services, community resources and client hygiene schedule.

Exit interview conducted with Mary Gonzales, a copy of this report was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023
LIC809 (FAS) - (06/04)
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