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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320438
Report Date: 01/29/2024
Date Signed: 01/29/2024 01:21:07 PM

Document Has Been Signed on 01/29/2024 01:21 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:SVS WEST TORRANCEINCLUSION CENTERFACILITY NUMBER:
198320438
ADMINISTRATOR:ESTRADA, CHRISTINAFACILITY TYPE:
775
ADDRESS:2606 SEPULVEDA BLVD.TELEPHONE:
(310) 944-3303
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY: 21CENSUS: 0DATE:
01/29/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Violet RuizTIME COMPLETED:
01:45 PM
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On 01/29/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an announced visit for a Pre-Licensing evaluation to the facility listed above. LPA met with Director of Regional Administration, Violet Ruiz, and the purpose of today's visit was explained.
An application was submitted to CCL on 11/09/23, for a change of location for the Adult Day Program to serve developmentally disabled adults aged 18 and over. The facility has been approved for 21 ambulatory clients, six (6) of which may be non-ambulatory.

Physical Plant/Structure The facility is a single-story structure in a commercial area. The facility consists of a reception area, conference room, four (4) offices, copy room, staff room, storage room, electrical room, locker room, Art Room, Leisure Room, kitchen, library, computer room, salon, Quiet Room, and four (4) restrooms. LPA inspected the inside and outside of the facility. LPA observed all walkways and hallways to be clean, clear, and free of debris, hazards, and obstructions. There were no bodies of water observed on the premises. The facility was maintained at a comfortable temperature.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2024
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: SVS WEST TORRANCEINCLUSION CENTER
FACILITY NUMBER: 198320438
VISIT DATE: 01/29/2024
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Rooms During the tour, LPA observed all rooms to be clean and in good repair. The facility was partially furnished due to the furniture at the current location of the day program. During today’s visit, LPA conducted a video walk through of the facilities current location to see the additional furniture that will be moved. In the Leisure Room, LPA observed a table, still awaiting to be moved is a couch, chairs, and activities. The Art Room was observed with a table, four (4) chairs, and art supplies. All scissors and art supply was observed secured in locked cabinets. An additional table, chairs, and supplies will be moved from the other location. The library was observed with two couches, and a cabinet with games and activities. A table and chairs will be moved from the other location. The computer room was observed with chairs. A table and four (4) computer chairs will be moved from the other location. The Quiet Room was observed with a table and cabinets. A lounge chair will be moved from the other location. The Salon was furnished with a table and three (3) chairs and equipment. An additional equipment and supplies will be moved from the other location. The locker room was observed with a row of lockers. Another row of lockers and bench will be moved from the other location. LPA observed staff offices with bookcases, filing cabinets, and a desk. Additional furniture will be moved from the other location. All rooms were observed with ample lighting.
Kitchen LPA observed the kitchen to be clean and sanitary. LPA observed all appliances to be in good repair, the two (2) refrigerators will be moved with the remainder of the furniture. LPA observed an ample supply of cookware, silverware, and cutleries. LPA observed a 7-day supply of non-perishable foods. LPA observed knives and sharps to be secured in a locked cabinet. The water temperature measured 106.4-degrees Fahrenheit. LPA observed multiple tables and chairs to accommodate clients.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024
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: SVS WEST TORRANCEINCLUSION CENTER
FACILITY NUMBER: 198320438
VISIT DATE: 01/29/2024
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Bathrooms LPA observed the facility has two (2) all gender single bathrooms, a women’s bathroom with two (2) stalls, and a men’s room with a stall and urinal. All safety handrails were securely fastened. The water temperature measured 118.4-degrees, 117.3-degrees, 119.2-degrees, and 117.6-degrees Fahrenheit. LPA observed an ample supply of hand soap and paper towels secured in a locked storage room.
Safety The facilities Fire Safety Inspection was granted on 12/21/23. LPA observed all smoke and carbon monoxide detectors to be in working order. LPA observed the fire extinguishers to be fully charged and last serviced on 11/20/23. All exits are clearly marked and open easily. The facility has a working landline telephone. LPA inspected the facility First Aid kit and observed it had the required items and a manual. Medications will be secured in a locked box in locked cabinet in a locked office. LPA reviewed the facilities Infection Control Plan and Emergency and Disaster Plan. LPA observed all cleaning supplies secured in the locked storage room.
Files Staff and Client files well be secured in a locked cabinet in locked staff office. The facility does not handle any of the Client’s finances.
Component III During today’s visit, LPA reviewed and discussed Component III with the facility Director of Regional Administration.

LPA did not observe any corrections to be addressed.

An exit interview was conducted with Director of Regional Administration, Violet Ruiz\, and a copy of this report was provided.

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

DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024
LIC809 (FAS) - (06/04)
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