198320071-5-31-2024-11-AS-PBUR-D5T8B8-20240531222155

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320071
Report Date: 05/30/2024
Date Signed: 05/31/2024 10:22:22 PM

Document Has Been Signed on 05/31/2024 10:22 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:	INCLUSION SPECIALIZED PROGRAMS,LLC - CONDON		FACILITY NUMBER:	198320071
ADMINISTRATOR/ DIRECTOR:	MACIAS, BLANCA		FACILITY TYPE:	738
ADDRESS:	10521 CONDON AVE		TELEPHONE:	(562) 968-0605
CITY:	INGLEWOOD	STATE: CA	ZIP CODE:	90304
CAPACITY: 4		CENSUS: 3	DATE:	05/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:00 PM
MET WITH:	Judex Nkwocha		TIME VISIT/ INSPECTION COMPLETED:	03:30 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	Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced required 1- year visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA was properly screened for COVID-19 symptoms and temperature was checked. LPA Bunker met House Manager Judex Nkwocha and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved mitigation plan report. There are currently three (3), Westside Regional Center (WRC) Adult Residential Care Facility (ARF) consumers in placement. The facility's annual fees are current. 12 Domains will be observed and reviewed. "LPA Bunker will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections." The facility is a single-family home located in a residential neighborhood. LPA Bunker and Mr. Nkwocha toured the facility which consisted of the following: Living room, kitchen, dining room, office area, seating room, 4 bedrooms, 2 bathrooms, laundry room, shaded patio area, storage room, detached garage, and indoor/outdoor activity areas. The front and back yard landscape is in good condition at the time of the visit. During the tour, LPA observed the facility’s infection control practices. During the tour, LPA Bunker observed a sanitizing station; hand sanitizer, visitor sign-in log, and thermometer at the facility's front entrance. Logs of daily COVID-19 screening and temperature checks of clients and staff were available and updated. See continued LIC809-C page 2

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024

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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: INCLUSION SPECIALIZED PROGRAMS,LLC - CONDON	FACILITY NUMBER: 198320071
	VISIT DATE: 05/30/2024

NARRATIVE

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Continued LIC809-C page 2

PPE supplies are readily available to staff, and an additional supply of PPE was observed. Sufficient liquid soap, paper goods, cleaning, and disinfecting supplies were observed. LPA observed staff and residents wearing a face covering and social distancing. House Manager Judex Nkwocha indicates that staff reviews the PINS and is up to date on the PINs.

Documents are posted as mandated on the wall and the office area. Bedrooms contain the furniture mandated, and the bathrooms are clean and operational. Personal accommodations were observed for safety, privacy, comfort, and non-skid surface mats. The kitchen was observed for its ability to prepare and serve food. The food service was reviewed for appropriate quantity and proper storage; there was an ample supply of perishable and nonperishable food. The resident’s medications were reviewed for proper storage, documentation, and system implementation. Medications are in a locked cabinet in the kitchen, and records are current. Common areas were observed for the ability to safely serve the needs of the clients, including cleanliness, and clearness of any potential hazards to the residents. The first aid kit is fully stocked with manual, smoke, and carbon monoxide detectors were in compliance, the hot water temperature was measured at 110 degrees Fahrenheit within the normal limits (105-120F degrees), the fire extinguishers are fully charged, adequate linen supply, the facility telephones are working. The client's bedroom windows have no sliding window lock with thumbscrews, all exit doors were in compliance, the yard was free of debris hazards, and trash cans were covered. Staff was given training on dependent adult and elder abuse reporting. The facility conducted a fire drill on May 18, 2024.

Due to time constraints, LPA was unable to complete the visit and will return back at a later date to complete the visit.

There were no deficiencies cited.

Exit interview conducted.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024

LIC809 (FAS) - (06/04)

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