<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320073
Report Date: 08/03/2024
Date Signed: 08/03/2024 10:47:07 AM

Document Has Been Signed on 08/03/2024 10:47 AM - 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-WEST 130THFACILITY NUMBER:
198320073
ADMINISTRATOR/
DIRECTOR:		COOK, DAVIDFACILITY TYPE:
738
ADDRESS:4442 W. 130TH STTELEPHONE:
(626) 476-2341
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY: 4CENSUS: 1DATE:
08/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:33 AM
MET WITH:Tony MadukaTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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 08/03/2024, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Staff Tony Maduka and Staff Brandie Gallegos. LPA explained the purpose of the visit and was accompanied by Staff inside and outside the facility during this inspection.

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

Outside grounds were toured and no bodies of water were observed. Patio furniture under a shaded area was accessible to clients. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

Client’s bedrooms were checked. Adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Bath towels were adequately stocked. Bathroom toilets and water faucets worked properly. LPA Cloyd tested hot water temperature and it measured at 116.4 degrees Fahrenheit. This facility provides clients with hygiene products such as nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb. Fire extinguisher in the kitchen serviced June 24, 2024.
Continue to LIC809-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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-WEST 130TH
FACILITY NUMBER: 198320073
VISIT DATE: 08/03/2024
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
26
27
28
29
30
31
32
LPA observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days.

LPA observed that Medications were safe, locked and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. Last Disaster drill was conducted on 05/24/24. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational.

Five (5) staff records were reviewed, 5 out of 5 staff records had required criminal record clearances or criminal record exemptions.

One (1) client records were reviewed and, 1 out of 1 client records had Admission Agreements, Medical Assessments, Pre-appraisals (or Reappraisals) and/or Needs & Services Plans. One client medication was reviewed.

No deficiencies cited at this time.

An exit interview was conducted, technical assistance provided, and a copy of this report was discussed and left with Staff Tony Maduka and Brandie Gallegos.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2