565802422-5-14-2024-34-CR-RYGY-D59LHT-20240514084653

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802422
Report Date: 05/09/2024
Date Signed: 05/14/2024 08:49:36 AM

Document Has Been Signed on 05/14/2024 08:49 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 CRP RO, 300 N. CONTINENTAL BLVD. #290B
EL SEGUNDO, CA 90245

FACILITY NAME:	DYER SMALL FAMILY HOME		FACILITY NUMBER:	565802422
ADMINISTRATOR/ DIRECTOR:	DYER, RYAN		FACILITY TYPE:	710
ADDRESS:	628 VERDEMONT CIRCLE		TELEPHONE:	(805) 624-7907
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY: 4		CENSUS: 4	DATE:	05/09/2024
TYPE OF VISIT:	Annual/Required	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Ryan Dyer Facility Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 05/09/2024 at 10:00 AM Licensing Program Analyst (LPA) Rosslyn Gray arrived at the above facility, for the purpose of conducting an Annual Required Inspection on the Dyer Small Family Home. A Health and Risk assessment was conducted upon arrival at the facility. The facility is licensed to provide care and supervision for four (4) developmentally disable male children ages 3-17 years old. Ambulatory only. There is currently four (4) male NonMinor Dependents (NMD) in placement. The administrator reported referrals are from the placement agency Tri-County Regional Center. LPA met with the Ryan Dyer Facility Administrator (FA), who granted access into the home and toured the facility both inside and out. This is a two story house with 5 bedrooms, one bedroom is being utilized as a bedroom for staff. There are three (3) bathrooms, Living Room, family room, Dining area, kitchen, laundry area and attached 3 cars garage. There are 2 fireplaces in the home with a secured screen attached and made inaccessible to the consumers.There is a body of water on the premises, a spa with a tight fitted locked cover that meets the regulations.The Licensee confirmed that there are no firearms or dangerous weapons in the facility. LPA-Gray observed the follow during the inspection: There is a three (3)-car garage utilized for storage. Vehicle #1 is parked outside of the garage will be utilized as needed. Make & Model 2020 BMW-X5; Registration Expiration 08/12/2024. Proof of Insurance is for both vehicles. (National Liability July 13, 2024); Vehicle #2 is utilized to transport the clients; Make & Model 2011 BMW-X5; Registration. The Make and Model (2018 330 BMW-X5); Registration (Expiration 07/19/2024. The Licensee displayed his Driver’s License expiration June 6, 2025. Both vehicles were checked for tires, headlights, taillights, turn signals, horn, and windshield wipers). The Licensee ensured that no smoking is allowed in in either of the vehicles. Outdoor Area: The activity space is free of hazard materials and debris. The ground is completed covered with green turf grass. There is recreational equipment the includes a Putting Green, Ping Pong Table, Hockey/ Soccer net and several fruit trees. The Hot Water Heater is located in the garage. Two air conditioning units.

SUPERVISORS NAME: JoAunne Griffin
LICENSING EVALUATOR NAME: Rosslyn Y. Gray
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CRP RO, 300 N. CONTINENTAL BLVD. #290B
EL SEGUNDO, CA 90245

FACILITY NAME: DYER SMALL FAMILY HOME	FACILITY NUMBER: 565802422
	VISIT DATE: 05/09/2024

NARRATIVE

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The facility trash cans are located on the west side of the house. LPA observed all windows, screens, and blinds drapes from the inside and outside of the facility were observed to be in good condition. The passageways and porches are unobstructed.

All posting requirements were met, (i.e Facility License, food menu, regulations, the Emergency Disaster plan, the personal rights, the facility sketch, and contact for local physicians, dental and mental health professional. The cleaning supplies solutions, disinfectants sharp knives are also inaccessible in key locked cabinet in the under the wet bar. LPA observed a blue tooth enter connected combined Smoke detector and Carbon Monoxide; tested to be operable.

1st Floor: LPA-Gray observed the following.

Bedroom #5(downstairs) is used as a staff room.

is equipped with comfortable mattress, clean linen, double sliding closet doors, 3 drawer dresser, a lounge chair, a ceiling fan, There is adequate lighting and the windows and drapes.

Living Room: There are 3 television, two sofas, 1 reclining chair.

Family Room: There is adequate furniture which appears to be in good condition.
Dining Area: Breakfast nook, game room, dining table observed with (4) chairs.
Kitchen: There is a stove/oven with (6) burners all working properly at this time. There is a microwave and double door refrigerator/freezer. The food service in the home is adequate with perishable/nonperishable food supplies. Caregiver ensures three nutritious meals, snacks. Knives/ Sharp objects are stored in the kitchen and are kept locked. Chemicals and cleaning solutions are kept in locked. The medication will be centrally located in the cabinet by the family room on the first floor.
2nd Floor: LPA-Gray observed the follow during the inspection:
Bedrooms:
Each bedroom is equipped with comfortable mattresses, clean linen, closet doors, 3 drawer dresser, a lounge chair, s adequate lighting and the windows and drapes. All observed to be in good condition

Bedroom #1: Occupied by Licensee. LPA observed a king bed, private bath, closets and dresser. There is a private balcony and an emergency exit with stairs. Bedroom is locked and clients are not permitted within this room or on this balcony.

SUPERVISORS NAME: JoAunne Griffin
LICENSING EVALUATOR NAME: Rosslyn Y. Gray
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

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 CRP RO, 300 N. CONTINENTAL BLVD. #290B
EL SEGUNDO, CA 90245

FACILITY NAME: DYER SMALL FAMILY HOME	FACILITY NUMBER: 565802422
	VISIT DATE: 05/09/2024

NARRATIVE

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Bedroom #2: is occupied by client #1. LPA observed a twin bed, walk in closet, dresser and chair.
Bedroom #3: is occupied by client #2. LPA observed a Full sized twin bed, dresser and closet.
Bedroom #4: is occupied by clients #3 and #4. LPA observed two full sized beds, wall dresser and closet. This bedroom has a fireplace that is secured and non functional. The bedroom has a balcony that is locked and non- accessible to clients.
Bathrooms: There are three (3) bathrooms equipped with bathroom with a tub, shower, sink and toilet; inspected and found to be clean. Bathroom #1 is located is located on the 1st floor, bedroom is located in #2 #3 is located hallway in between 2 and 3. LPA ensured that all toilets flushed, and tested water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. LPA observed two fire extinguishers in the home all in working condition. There is adequate linen supply in the hallway closet. LPA observed that all materials required to be posted in the living room and posted in visible way to all clients. LPA ensured that all toilets flushed, and tested water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. There is a Jacuzzi on the on the premises but it is locked and is not utilized by anyone.

The Small Family Home operates within license conditions and limitations including capacity limitations. Facility personnel are instructed to report violations of personal rights. Licensee will report changes in the plan of operation affecting service to clients. Licensee will report client injuries requiring medical treatment. LPA reviewed the Licensee’s Training certificates (Certified by the Board of Registered Nurses) LPA obtained the Facility Profile and Personnel Report and confirmed that the Licensee have required criminal record clearance. DOJ, FBI and Child Abuse Response; which meet qualification.

Client Records: LPA reviewed four (4) client records on file.

Staff Records: LPA reviewed four (4) staff record.

Client Interviews: No interviews were conduct due to the children being at school at the time of the inspections, in addition to reportedly being non verbal.

Staff Interviews: LPA interviewed three (3) staff on duty identified as the administrator.

There were no deficiencies cited at this time.

LPA concluded the Annual/Required. An exit interview was conducted, and a copy of this report was left at the facility with the Ryan Dyer Facility Administrator

SUPERVISORS NAME: JoAunne Griffin
LICENSING EVALUATOR NAME: Rosslyn Y. Gray
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

LIC809 (FAS) - (06/04)

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