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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603362
Report Date: 08/28/2024
Date Signed: 08/28/2024 11:36:51 AM

Document Has Been Signed on 08/28/2024 11:36 AM - 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:DUNGARVIN CALIFORNIA - SIGNAL HILLFACILITY NUMBER:
198603362
ADMINISTRATOR/
DIRECTOR:
MARTIN, ALLISONFACILITY TYPE:
775
ADDRESS:695 EAST 27TH STREETTELEPHONE:
(510) 727-9448
CITY:SIGNAL HILLSTATE: CAZIP CODE:
90755
CAPACITY: 30CENSUS: 21DATE:
08/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Director Juan ZepedaTIME VISIT/
INSPECTION COMPLETED:
11:55 AM
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On 08/28/24, Licensing Program Analyst (LPA) Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Director Juan Zepeda as the purpose of the visit was explained. The facility is licensed for a capacity of 30 adults ages 18-59 of which 10 may be non-ambulatory. Day program consumers are linked to the Harbor Regional center, the staff to consumer ratio is (1) staff to (3) consumers. Director was provided with upcoming fees info.

The property consists of (1) large building which includes a garden room, music room, art room, tech room life skills room, gaming room, exercise room, library, conference room, administrative offices, kitchen, (3) unisex bathrooms and an outside patio. The Facility walls and floors were in good condition, storage space for consumers to utilize, adequate lighting and sufficient furniture observed throughout the facility. Chemicals and sharps were properly locked, first aid kit was fully stocked, restrooms were clean and within Title 22 regulations. Landline and internet service were observed, smoke alarms and carbon monoxide are hardwired and operational. Consumers bring their own meals and program provides snacks only, there are 2 consumers who have medications at the day program, LPA observed medication administration training on file. LPA conducted a review of (5) consumer records, and (3) staff records, no discrepancies observed. The last fire drill conducted was on 07/10/24 during both the AM and PM sessions. LPA observed (3) fire extinguishers were observed throughout the facility. There are no bodies of water nor obstructions on the premises, walkways throughout the day program and all exits were clear of hazards and debris.

Exit interview conducted with Director Juan Zepeda, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2024
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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