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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004154
Report Date: 06/02/2023
Date Signed: 06/02/2023 03:08:41 PM

Document Has Been Signed on 06/02/2023 03:08 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:DE LEON HOME-BILLY'SFACILITY NUMBER:
306004154
ADMINISTRATOR:CATHERINE CAROTHERSFACILITY TYPE:
735
ADDRESS:11639 175TH STREETTELEPHONE:
(562) 900-8789
CITY:ARTESIASTATE: CAZIP CODE:
90701
CAPACITY: 4CENSUS: 3DATE:
06/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:House Manager Angel DuranTIME COMPLETED:
03:22 PM
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On 6/2/23 at 12:30 p.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual/Required inspection to De Leon Home- Billy. Upon arrival LPA was greeted by House Manger (HM) Angel Duran who contacted the Administrator, Carrie Carothers, at 12:35 p.m. to assist with today's visit. This home is licensed to serve (2) non-Ambulatory and (2) Ambulatory developmentally disabled adults. The is a level 4I home and the vendor is Harbor Regional Center. There were (3) clients in care during the time of this visit. The last emergency disaster/fire drill was conducted on 5/1/2023. The Administrator Certificate expires on 11/08/2023 #6008460735. 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, medication administration records for (3) clients and P&I. LPA (1) interviewed staff and due to all clients limited communication LPA could not proceed with client interviews. LPA attempted to interview 1 client.

This home contains 4 bedrooms,1 staff bedroom, 1 bathroom, 1 staff bathroom, 2 living room, kitchen, dining room and a detached garage. LPA toured the physical plant and observed all (4) 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 bathmat. The temperature measured at 110.3*F-113.1*F. The smoke detectors were battery operated and individually tested and observed to be working properly.

(Report continued on LIC809C.)
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2023
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: DE LEON HOME-BILLY'S
FACILITY NUMBER: 306004154
VISIT DATE: 06/02/2023
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The carbon monoxide detector was located throughout the facility, tested, and functioning properly. There were (1) fire extinguisher located in kitchen and dining room 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 the cabinet. The cleaning agents and toxins was locked underneath the kitchen sink. The pantry was well stocked with canned goods, pasta, cereals, 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.

The outdoor grounds were toured and inspected, and the patio was well maintained with a shaded seating area accessible for client use. The garage contained PPE supplies and storage.


Exit interview conducted with Angel Duran, House Manager, a copy of this report was provided, and Appeal rights given.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
LIC809 (FAS) - (06/04)
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