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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610397
Report Date: 06/22/2023
Date Signed: 06/22/2023 01:56:53 PM

Document Has Been Signed on 06/22/2023 01:56 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ICON-ADPFACILITY NUMBER:
197610397
ADMINISTRATOR:BROWN, DEWALTFACILITY TYPE:
775
ADDRESS:2369 LINCOLN AVETELEPHONE:
(626) 926-3519
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY: 120CENSUS: 0DATE:
06/22/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:59 AM
MET WITH:Dewalt Brown - Licensee RepTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Gary Tan made an announced visit to this facility to conduct a Pre-licensing visit and Component III orientation. An initial application to operate an Adult Day Program for Adults ages 18 and older with developmental disabilities was submitted by applicant Integrated Community Options, Inc. A fire clearance for 120 ambulatory, 20 of which may be non-ambulatory was approved on April 23, 2023. LPA met with Licensee Representative Dewalt Brown.

LPA toured the facility with Mr. Brown at 10:15 AM and the following was observed:

Days & Hours: Facility will operate Monday through Friday from 9:00 AM through 3:00 PM
Structure. The facility is a one (1) storey building located in a commercially zoned neighborhood.
The Adult day Program will be used by the clients for recreation, educational and life skills purposes.
Client Resting. Available in reception area and other activity room. Visible to office staff.
Bathrooms. There are working four (4) working toilets and one (1) hand sanitation sink located in the main area. All toilets are ADA (American with Disabilities Act) compliant. There is a shower in the unisex restroom located in the back area that can be used to bathe clients if needed.
Client Personal Storage area:. To be procured upon operation.
Emergency Phone Numbers & Exit Plan. Posted on the wall.
Fire extinguishers and Smoke Detectors. Smoke alarms are hardwired and inter connected. There is a pull system in place. There is a carbon monoxide detector installed in the facility. There are five (5) fire extinguishers located all over the area, last inspected 03/20/23.
Appliances. There are six (6) television sets, two (2) refrigerators, a microwave oven and two (2) full stove range in the kitchen for staff use only. There is also a functioning telephone in the premises.
Food Service/ Menu:. Clients will bring their own food & snacks as needed. A full kitchen is available for occasional and celebratory use for staff and clients. (continued to LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2023
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ICON-ADP
FACILITY NUMBER: 197610397
VISIT DATE: 06/22/2023
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(continued from LIC 809)

Drinking Water. There are two (2) big refrigerator in the kitchen to store beverages and a hot/cold water dispenser will be procured upon operation.
Water Temperature. Tested at a range between 112.7°F to 117.8°F
Toxins. All toxins, cleaning agents and tools are locked in the garage at the back parking area.
Clients & Staff Files. Will be locked/stored in the office area/file cabinets.
First Aid and Medications. Facility will not handle medications. If needed, the kitchen has locked cabinet to store the medications, There are two (2) complete first aid kits in the kitchen.
Activities: There are six (6) customizable classroom/activity areas and kitchen.
Outdoor Space: Fully fenced and gated outdoor. There will be outdoor activities in place upon operation such as table tennis, basketball and other outdoor activity.

The facility is equipped with Close Circuit Television (CCTV) system inside and outside of the facility for safety and security.

The Licensee Representative will be the administrator of this facility (No. 6018734735, expiration 10/15/24). The request for Component III to be waived at this facility has been granted by LPM Troy Agard as the Licensee Representative is a long time operator of Adult Residential Facility and community based Adult day program.

Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved.

Exit interview conducted and copy of this report issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
LIC809 (FAS) - (06/04)
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