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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320073
Report Date: 11/23/2022
Date Signed: 01/06/2023 04:13:19 PM

Document Has Been Signed on 01/06/2023 04:13 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:INCLUSION SPECIALIZED PROGRAMS,LLC-WEST 130THFACILITY NUMBER:
198320073
ADMINISTRATOR:COOK, DAVIDFACILITY TYPE:
738
ADDRESS:4442 W. 130TH STTELEPHONE:
(626) 476-2341
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY: 4CENSUS: DATE:
11/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:TIME COMPLETED:
12:15 PM
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On November 23, 2022, Licensing Program Analyst (LPA), Wendy Gibbs made an unannounced annual visit with the primary focus on Infection Control using the CARE tools. LPA met with House Manager Diana Libiran and RBT Brandie Gallegos and explained the purpose of this visit. Administrator David Cook joined us 15 minutes into the visit.

Structure: The facility is a single-story home in a residential neighborhood. The home consists of 4 resident bedrooms, 2 resident bathroom, dining area, kitchen, living room, laundry area, family room, office area and a patio area in the backyard.

Physical Plant LPA walked the outside of the facility. There was a shaded patio with a table and chairs available for use. All walkways were free of debris and obstructions. There were no bodies of water on the premises.

Bedroom Resident bedrooms had the required furniture. There was a bed, nightstand, chair, dresser and closet space to accommodate each resident comfortably. Beds have the required linen/supplies which include, pillowcase, fitted sheet, blanket and bedspreads.

Bathrooms Resident bathrooms were checked. Toilets and water faucets worked properly, shower was free of mold/mildew, had non-skid mats and secured grab bars. The water temperature measured between 113.5 to 114.5 degrees F.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE: DATE: 11/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/23/2022
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: INCLUSION SPECIALIZED PROGRAMS,LLC-WEST 130TH
FACILITY NUMBER: 198320073
VISIT DATE: 11/23/2022
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Linens & Hygiene Supplies: Resident bath towels, toiletries and personal hygiene supplies were adequately stocked.

Emergency Phone Numbers, Exit Plan, & Menu: Emergency numbers are posted and readily available for review in the hallway area. Facility has a land line telephone. The facility has 2 fully charged fire extinguishers last serviced on 06/08/22. The last disaster drill was on 11/04/22. Facility smoke/carbon monoxide detectors were tested and in good working order.

Kitchen: Dishes, cups, and flatware are stored in the facility’s kitchen. The stove burners, gas oven, and microwave are in good working condition. LPA observed an ample supply of food. A 7-day supply of non-perishable and a 3 day supply of perishable. All sharps are locked in a drawer and not accessible to residents. The water temperature measured 114.2

Toxins: Cleaning supplies, and toxins are stored in cabinet under kitchen sink. There are additional cleaning supplies locked in a shed in the back yard.

Medication, First-Aid Kit & Book: Designated centrally stored medication are stored inside of a locked cabinet in the kitchen. LPA reviewed all resident’s medication and matched them to the MARs. First-aid kit has a sufficient supply of all necessary items and a manual.

Clients & Staff Files: LPA reviewed three resident files that all contained necessary documentation. LPA reviewed three staff files and they contained all necessary documentation. LPA reviewed the Surety Bond.

Reading Material, Games, Equipment & Materials: The facility has books, board games, X Box and other recreational materials for the client's use.

There were no deficiencies cited.

Exit interview was conducted with Administrator David Cook

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2022
LIC809 (FAS) - (06/04)
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