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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603335
Report Date: 05/04/2026
Date Signed: 05/04/2026 03:11:51 PM

Document Has Been Signed on 05/04/2026 03:11 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/
DIRECTOR:		GONZALES, LUIS S.FACILITY TYPE:
735
ADDRESS:18104 DEVLIN AVE.TELEPHONE:
(562) 552-5579
CITY:ARTESIASTATE: CAZIP CODE:
90701
CAPACITY: 3CENSUS: 2DATE:
05/04/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Administrators Mira and Archimedes LopezTIME VISIT/
INSPECTION COMPLETED:
03:27 PM
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On 5/04/26, Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual/Required inspection to PDM Delvin Home. Upon arrival LPA was greeted by Administrator Mira Lopez. Administrator Archimedes Lopez joined the visit 10 minutes later. LPA explained the reason for the visit. This home is licensed to serve (3) Developmentally Disabled Adults, (3) non-Ambulatory and (3) maybe bedridden. The clients served are between the ages of 18 through 59 with 1 hospice wavier, vendorized by Harbor Regional Center. There were (2) 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 4/6/2026. The Administrator Certificate expires on 6/3/2027. 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, (2) client files, medications, and medication administration records for (2) clients and P&I.

This home contains 3 bedrooms, 1 bathroom, 2 staff bathroom, living room, kitchen, dining room/office area, 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 client’s bathrooms contain a working toilet, basin, and water faucet, walk in shower with grab bar, shower chair, and skid mats. The water temperature was measured at 118.0*F-119.7*F. The smoke detectors were battery operated and tested and observed to be working properly.

(Report continued on LIC809C.)

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2026
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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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: 05/04/2026
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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.

The outdoor grounds were toured and inspected, and the patio was well maintained with shaded seated area. The garage contained washer and dryer, storage, PPE supplies, cleaning agents, 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 Mira Lopez, a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2026
LIC809 (FAS) - (06/04)
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