198603362-9-9-2021-11-AS-JJON-C6PSYK-20210909141741

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603362
Report Date: 09/09/2021
Date Signed: 09/09/2021 02:17:43 PM

Document Has Been Signed on 09/09/2021 02:17 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	DUNGARVIN CALIFORNIA - SIGNAL HILL		FACILITY NUMBER:	198603362
ADMINISTRATOR:	MARTIN, ALLISON		FACILITY TYPE:	775
ADDRESS:	695 EAST 27TH STREET		TELEPHONE:	(510) 727-9448
CITY:	SIGNAL HILL	STATE: CA	ZIP CODE:	90755
CAPACITY: 30		CENSUS: 15	DATE:	09/09/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Ollie Martin		TIME COMPLETED:	02:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Jade Jordan made an unannounced visit to Dungarvin California (ADP) located at 695 E. 27th Street Signal Hill Ca. The purpose of today's visit was to conduct an Annual Inspection with an emphasis on infection control. During todays visit LPA was met by Program Director Ollie Martin.

As part of today's inspection LPA reviewed infection control measures set in place at the facility. LPA was screen prior to entry, and then filled out a questioner regarding Covid 19 related symptoms. The facility has has this screening in place for all staff, consumers and visitors. The program is currently operating virtually, but plans to have a small group of consumers return on site effective 09/13/21. The LPA and Director toured the entire facility. The property consists of 1 large building with 10 large activity area, which include a Garden room, music room, art room, tech room offices, sewing room, gaming room, exercise room, library, conference room, kitchen and 3 unisex bathrooms and an outside patio.

The Facility walls and floors were in good condition, adequate lighting, fire extinguishers were properly charged. Plenty of storage space and chemicals were properly locked. The restrooms were clean and within Title 22 regulations. An emergency water and food supply was available. The kitchen was clean, and a refrigerator was available for consumer use. The day program does not provide meals at this time due to Covid, but emergency snacks/food are available to consumers if they forget to bring a meal. The first aid kit was available; Walkways throughout the day program were clear of hazards and all exits were clear of debris. Lpa sampled staff and resident files, all of which had the required documentation.

LPA observed all staff to be wearing masks, and practicing social distancing. Lpa observed over a 30 day supply of PPE present within the facility, and ample sanitizing and disinfectant products. . No citations were issued during this visit and a copy of this report was provided.

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

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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