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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600461
Report Date: 03/22/2024
Date Signed: 03/22/2024 03:55:54 PM

Document Has Been Signed on 03/22/2024 03:55 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:ADULT DEVELOPMENT CENTER - HERMOSA BEACHFACILITY NUMBER:
191600461
ADMINISTRATOR:LEUCI, MARYFACILITY TYPE:
775
ADDRESS:710 PIER AVE.TELEPHONE:
(310) 318-9343
CITY:HERMOSA BEACHSTATE: CAZIP CODE:
90254
CAPACITY: 52CENSUS: 16DATE:
03/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:06 AM
MET WITH:Program Manager Vince IvoryTIME COMPLETED:
04:30 PM
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On 03/22/204 at 8:00 am Licensing Program Analyst (LPA) David España conducted an unannounced Required-1-year annual visit. Upon arrival at the facility, LPA España conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection (No COVID-19 cases). LPA verified that the facility has an approved mitigation plan report. LPA was granted access and allowed to enter the facility to conduct the inspection. On today's visit LPA met with facility Program Manager Vince Ivory.

LPA España confirmed the census of Sixteen (16). LPA España confirmed there are Ten (10) non-verbal client who only communicate through pictures. LPA España confirmed there are Four (4) verbal client. LPA España confirmed there are Four (4) non-verbal client who do not speak. LPA España interviewed Four (4) staff members. The Adult Day Programs (ADP) facility is licensed for a capacity of Fifty-Two (52) clients (Eight (8) non-ambulatory and 44 ambulatories). The program manager stated that the program has Sixteen (16) clients enrolled in the program. LPA España confirmed present during visit Fifteen (15) clients. The staff to client ratio is One (1) staff to Four (4) clients. Program Manager stated that the program has 0 clients with a Restricted Health Care condition. Continued on LIC809C

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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: ADULT DEVELOPMENT CENTER - HERMOSA BEACH
FACILITY NUMBER: 191600461
VISIT DATE: 03/22/2024
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LPA España confirmed there are Three (3) or Four (4) time a week field trips. LPA España confirmed that facility staff hold discussions with clients concerning field trips. LPA España confirmed there are specific groups associated with caregivers when on field trips. LPA España confirmed there is One (1) van. Currently, there are Zero (0) clients using protective devices. The program conducted a fire drill in 03/14/2024 and a Disaster Plan was on file. The program does not provide transportation. As a part of today's inspection LPA reviewed Five (5) client records, and Five (5) staff records, and inspected the entire facility inside and out. LPA and Program Manager Vince Ivory toured the entire facility. The property consists of main office, conference room, kitchen, Two (2) activity classroom, computer room, and Two (2) bathrooms are available for use by clients/staff that are part of the community center. The facility program is (vendor) through Harbor Regional Center clients. There are no bodies of water or firearm/ammunition on the premises. The activity rooms had plenty of storage space and client chairs. The kitchen is in repair now. Cleaning supplies were locked. All the rooms that were inspected were clean. Activity rooms had Two (2) first aid kits and Two (2) fire extinguisher that were fully charge. Smoke detectors and carbon monoxide were working. Walls and floors were in good repair. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured were found to be within Title 22 regulations and were clean and operational. A comfortable temperature is maintained in the facility. There was Technical Assistance provided on today’s visit. Continued LIC809C
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: ADULT DEVELOPMENT CENTER - HERMOSA BEACH
FACILITY NUMBER: 191600461
VISIT DATE: 03/22/2024
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Physical Plant & Environmental Safety - Technical Assistance: 82087(a) - LPA España and Program Manager Vince Ivory observed Two (2) activity classroom to have carpet in despair, unrepaired chipped wall by window in classroom with disrepair texture, and heating system in disrepair in activity classroom.

Exit interview conducted and a copy of the appeal rights were given to Program Manager Vince Ivory.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
LIC809 (FAS) - (06/04)
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