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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198200516
Report Date: 10/02/2023
Date Signed: 10/02/2023 03:39:28 PM

Document Has Been Signed on 10/02/2023 03:39 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:SOCIAL VOCATIONAL SERVICES LOMITA RESIDENTIAL HOMEFACILITY NUMBER:
198200516
ADMINISTRATOR:SHARON HOPPERFACILITY TYPE:
735
ADDRESS:24512 WOODWARD AVENUETELEPHONE:
(310) 517-0960
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY: 6CENSUS: 3DATE:
10/02/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:BRENDA REALTIME COMPLETED:
04:00 PM
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On 10/2/2023 at 2:15 pm, Licensing Program Analyst (LPA) Lourdes Montoya made an unannounced case management visit to obtain additional information regarding an Unusual Incident/Injury Report at this facility. LPA was greeted by Staff Brenda Real who confirmed the facility is free of Covid-19. LPA explained the purpose of the visit. Staff Real called the Program Director Vincent Nguyen and Nguyen assisted with the visit via telephone.

LPA requested and obtained copies of Client #1’s records pertinent to the incident: Annual IPP dated 4/27/2023, Behavioral Program report dated 2/23/22-4/20/23, Behavioral Intervention dated 4/11/2023, and Emergency Room After Visit Summary dated 9/30/23. Nguyen will email other pertinent records.

Program Director Nguyen and Staff Real explained C1 sustains bruises from falls, unbalanced gait, age and maybe combination of these.

LPA explained the department will review C1’s records and will conduct a follow-up call or visit if needed.

Exit interview conducted and a copy of the report was provided to Staff Brenda Real.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 10/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2023
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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