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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603362
Report Date: 03/22/2023
Date Signed: 03/22/2023 02:15:31 PM

Document Has Been Signed on 03/22/2023 02:15 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:DUNGARVIN CALIFORNIA - SIGNAL HILLFACILITY NUMBER:
198603362
ADMINISTRATOR:MARTIN, ALLISONFACILITY TYPE:
775
ADDRESS:695 EAST 27TH STREETTELEPHONE:
(510) 727-9448
CITY:SIGNAL HILLSTATE: CAZIP CODE:
90755
CAPACITY: 30CENSUS: 11DATE:
03/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:48 PM
MET WITH:Beverly Ruiz, Program DirectorTIME COMPLETED:
02:19 PM
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On 3/22/23 Licensing Program Analyst (LPA) Mario Leon conducted an unannounced Case Management inspection. LPA met with Beverly Ruiz , Program Director to interview about the events of 2/28/23. The purpose of today's visit involved gathering additional details surrounding the death of Client #1 which occurred on February 28, 2023.

During the visit LPA reviewed Client #1's file and requested copies of supportive documents (Most current IPP, departure sign-out chart via Reliable Transport on 2/28/23 and the contact number and Driver's first name). The facility has provided CCLD with the necessary documents requested, and has completed a Death report and SIR within the required time frame.

Investigation:
LPA interviewed Beverly Ruiz regarding Client #1's day and departure events as well as any abnormalities.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2023
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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