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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320444
Report Date: 08/08/2024
Date Signed: 08/08/2024 11:08:39 AM

Document Has Been Signed on 08/08/2024 11:08 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:SOCIAL VOCATIONAL SERVICES., HAWTHORNE INCLUSION CFACILITY NUMBER:
198320444
ADMINISTRATOR/
DIRECTOR:		CARABANTES, HUGOFACILITY TYPE:
775
ADDRESS:14015 HAWTHORNE BLVD.TELEPHONE:
(310) 944-3303
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY: 45CENSUS: 0DATE:
08/08/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:VIOLETA RUIZTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On 08/08/2024, Licensing Program Analyst (LPA) Antonine Richard conducted announced visit to this Adult Day Program. LPA was greeted by applicant Violeta Ruiz and Angie Gallon explained the purpose of today’s pre-licensing inspection visit.

An application was submitted to CCLD on 12/11/2023 in the initial license application for an Adult Day Program for the Adult, ages 18 years through 59. The applicant requested a capacity of forty-five (45) individuals, of which maybe six (6) non-ambulatory, thirty-nine (39) ambulatory, and zero (0) bedridden.

Structure:
The Day Program consists of seven (7) activity rooms, five (5) offices. One (1) staff breakroom, three (3) bathrooms, (2) storage rooms, one (1) janitor and one (1) reception area. One story building situated in a residential neighborhood. The building includes a kitchen with two round tables that sit eight individuals. The kitchen has a refrigerator, microwave, dishwasher, and a stove. The rear exterior is fenced throughout. The passageways, walkways, are free from obstructions.

Evaluation Report Continues
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2024
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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: SOCIAL VOCATIONAL SERVICES., HAWTHORNE INCLUSION C
FACILITY NUMBER: 198320444
VISIT DATE: 08/08/2024
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Bathrooms:
The Adult Day Program has three (3) bathrooms. Bathrooms are accessible. All bathrooms have a working toilet.

Emergency Phone Numbers, Exit Plan:
Emergency phone numbers. The exit plan and activity schedules are posted and readily available for review on bulletin board. There are five (5) fire extinguishers located throughout the Day Program. Telephone lines are available in the Day program. Emergency supplies and Personal Protective Equipment supplies are stored in the Hallway cabinets. The applicant has an approved Infection Control Plan on file.

Food Service:
Dishes, cups, and flatware are stored in the kitchen cabinets, inspected, and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in a locked kitchen drawer. Food supply is adequately stored in kitchen cabinets and consists of can goods. The kitchen counters also have small appliances.

Smoke Detectors:
(23) Smoke and carbon monoxide hardwired detectors throughout the interior space.

Program Hours:
9: 00 AM to 2 : 30 PM.
Monday through Friday.

Evaluation Report Continues
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

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

DATE: 08/08/2024
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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: SOCIAL VOCATIONAL SERVICES., HAWTHORNE INCLUSION C
FACILITY NUMBER: 198320444
VISIT DATE: 08/08/2024
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Toxins:
All toxins are locked and stored in the storage room.
Water Temperature:
The water temperature is 110.3F degrees, throughout the kitchen, break room and bathrooms.

Medications, First-Aid Kit & Book:
A first aid kit is stored in the medication cabinet inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze, and current first aid manual locked and inaccessible to individual. The individual’s medications will be stored in a mental cabinet locked in the office and inaccessible to individuals.

Adult & Staff Files:
The applicant is not handling the cash resources for individuals. Records of staff and individuals will be stored in a locked metal cabinet in the office.

Fire clearance:
A Fire Clearance inspection was conducted on 05/15/24 approved for a capacity for six (6) non-ambulatories, thirty-nine (39) for ambulatory, and zero (0) for bedridden.
Component III:
LPA Antonine Richard conducted the Pre-Licensing inspection along with the information provided about how to operate the Day Program within compliance of Component III Power Point.
Exit interview conducted. No deficiencies. A copy of the report was provided to the applicant Violeta Ruiz.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

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

DATE: 08/08/2024
LIC809 (FAS) - (06/04)
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