198320073-8-2-2023-11-AS-WGIS-CUC4H7-20230802190640

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320073
Report Date: 08/02/2023
Date Signed: 08/02/2023 07:06:46 PM

Document Has Been Signed on 08/02/2023 07:06 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 130TH		FACILITY NUMBER:	198320073
ADMINISTRATOR:	COOK, DAVID		FACILITY TYPE:	738
ADDRESS:	4442 W. 130TH ST		TELEPHONE:	(626) 476-2341
CITY:	HAWTHORNE	STATE: CA	ZIP CODE:	90250
CAPACITY: 4		CENSUS: 3	DATE:	08/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	David Cook		TIME COMPLETED:	02:30 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	On 08/02/23, Licensing Program Analyst (LPA), Wendy Gibbs made an unannounced annual visit using the CARE tools. LPA met with Administrator David Cook and explained the purpose of today’s visit. During the time of visit two (2) clients were present. Structure: The facility is a single-story home in a residential neighborhood. The home consists of 4 client 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 inspected the inside and outside of the facility. In the back there is a shaded patio with a table and chairs available for Client use. All walkways were clean, clear, and free of debris, hazards, and obstructions. All gates open easily from the inside for a quick exit. There were no bodies of water on the premises. Bedroom Client bedrooms were inspected. LPA observed the required furniture, including a bed, nightstand, dresser, chair, and ample storage space to accommodate Clients belonging. All bedrooms were observed to be clean and in good repair. Bathrooms Client bathrooms were inspected. All toilets, showers, and sinks were in good repair. The showers were observed to have non-skid mats, safety grab bars secured to the walls, and were free of mildew and mold. The water temperature measured between 113.5-degree to 117.2-degrees Fahrenheit. The bathrooms were observed to be clean and in good repair. Linens & Hygiene Supplies: LPA observed all Client beds to have the required linens including a matters cover, fitted sheets, blanket, comforter, and pillows. LPA observed an ample supply of bath towels, toiletries and personal hygiene supplies were adequately stocked. Kitchen: LPA observed the kitchen to be clean and sanitary. All cutleries, pots and pans were observed to be in good repair. All appliances, including stove, oven, microwave, dishwasher and microwave were observed in good repair. LPA observed a 3-day supply of perishable food and a 7-day supply of non-perishable foods. All food was labeled and properly stored.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

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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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: 08/02/2023

NARRATIVE

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All knives and sharps were secured in a locked drawer and cabinet in the kitchen and are inaccessible to Clients. LPA reviewed the daily sharps count from each shift. All cleaning supplies are stored in a locked cabinet under the kitchen sink and are inaccessible to Clients. An additional supplies of cleaning products are stored in a locked shed in the backyard and are inaccessible to Clients. The water temperature measured 107.2-degrees Fahrenheit.
Common Rooms LPA inspected all common rooms. The living room has two couches to accommodate all Clients. LPA observed games and activities in the entertainment center. The family room has a couch to accommodate all Clients. The dining room has a large rectangular table with chairs to accommodate all Clients. The facility was maintained at a comfortable temperature. All walkways and hallways were observed to be clean, clear, and free of obstructions or hazards. Safety: LPA observed all required documents posted throughout the facility, including Emergency Phone Numbers and Disaster Plan. LPA observed two (2) fully charged fire extinguisher, mounted on a wall in the family room, last serviced on 06/13/23. The sprinkler system and fire doors were last inspected and serviced on 06/02/23. The last emergency drill was conducted on 07/21/23. The facility has a working landline telephone. LPA inspected the First Aid Kit and found it contained the required items and a manual.
Infection Control Upon entry LPA was screened for any infectious diseases, and temperature was taken. Every visitor, staff and Client are screened upon entry. LPA reviewed the Client’s daily temperature log. LPA reviewed daily and weekly cleaning log. LPA observed required Infection Control signs posted throughout the facility. LPA observed all staff were wearing face masks.
Medication: LPA observed all centrally stored medications were stored in a locked cabinet in the kitchen and are inaccessible to Clients. LPA reviewed the medication administration record (MARs) and found it to be consistent with properly documented records.
File Review & Interviews: LPA reviewed three (3) resident files and found they contained the required documentation. LPA reviewed four (4) staff files and they contained the required certification, training, and documentation. LPA reviewed all Client’s P & I funds and reviewed the Surety Bond.

There were no deficiencies cited.

LPA conducted an exit interview with Administrator, David Cook, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

LIC809 (FAS) - (06/04)

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