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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004162
Report Date: 11/16/2024
Date Signed: 11/16/2024 11:43:39 AM

Document Has Been Signed on 11/16/2024 11:43 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:DE LEON HOMESFACILITY NUMBER:
306004162
ADMINISTRATOR/
DIRECTOR:		APRIL GORMANFACILITY TYPE:
735
ADDRESS:6100 E. WALTON STREETTELEPHONE:
(562) 354-6195
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY: 4CENSUS: 4DATE:
11/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:29 AM
MET WITH:April GormanTIME VISIT/
INSPECTION COMPLETED:
11:59 AM
NARRATIVE
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On 11/16/24, Licensing Program Analysts (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator April Gorman. LPA explained the purpose of today’s visit. The facility is licensed to operate for (4) ambulatory and (2) non-ambulatory adults 18 through 59. Currently, the facility has no hospice client in care. The facility is approved for (1) hospice client. The residents are all Harbor Regional Center consumers.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: (4) residents' rooms, (2) bathrooms, a living area, a dining area, a kitchen, a staff bedroom, an outside seating area, and a garage used for storage.

LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 106.0 degrees F. A comfortable temperature of 70 F. degrees was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. A fire extinguisher was charged. A review of the Medication Records Administration (MAR) was observed to be maintained in place.

LPA observed First Aid Kit was maintained. A working landline phone was operational. The last fire drill was conducted on 08/01/24. The facility had operational smoke and carbon monoxide in bedrooms and common areas.
(Evaluation Report continues LIC 809-C)
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2024
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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Document Has Been Signed on 11/16/2024 11:43 AM - It Cannot Be Edited


Created By: Ernand Dabuet On 11/16/2024 at 11:07 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: DE LEON HOMES
FACILITY NUMBER: 306004162

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on obsevation, the licensee did not comply with the section cited above. LPA identified cleaning solution 409 hanging on the kitchen oven not stored in locked area. The toxic solution was accessible to clients in care. This violation
which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/17/2024
Plan of Correction
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The licensee will ensure that all hazadous or toxic materials are not accessible to clients in care. Disenfectant materials must be stored in locked storage. Proof of correct must be sent to LPA ernand.dabuet@dss.ca.gov
*Correction was completed during visit*
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2024


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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: DE LEON HOMES
FACILITY NUMBER: 306004162
VISIT DATE: 11/16/2024
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During the visit, LPA observed the facility's infection control practices. LPAs observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted.

An audit of clients #1-#4 (C1-C4) service files and staff #1-#4 (S1-S4) personnel files revealed to be complete. An audit of the resident's P&I is maintained in order and complete. The facility has the current administrator's certification pending for renewal on file for April Gorman #7010115735.

DEFICIENCY:
LPA identified cleaning solution 409 hanging on the kitchen oven not stored in locked area. The toxic solution was accessible to clients in care.

Advisory Notes - Technical Violation (see LIC 9120)

An exit interview was conducted with April Gorman, a copy of the report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2024
LIC809 (FAS) - (06/04)
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