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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601138
Report Date: 10/25/2022
Date Signed: 10/25/2022 04:45:00 PM

Document Has Been Signed on 10/25/2022 04:45 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SOCIAL VOCATIONAL SERVICES NORWALK INCLUSION CENTEFACILITY NUMBER:
198601138
ADMINISTRATOR:MONICA VALENCIAFACILITY TYPE:
775
ADDRESS:11849 FIRESTONE BLVD.TELEPHONE:
(310) 944-3303
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 27CENSUS: 7DATE:
10/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Case Manager- Michelle DelgadoTIME COMPLETED:
04:50 PM
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On 10.25.22 , Licensing Program Analyst (LPA) Ashley Calderon arrived at the facility to conduct an unannounced annual required inspection. LPA Calderon met with Michelle Delagdo (Case Manager).

Today's visit consisted of LPA Calderon inspecting the entire physical plant facility with Delagdo. LPA Calderon inspected the reception area, three office rooms, locker area, staff break room, storage room, cyber room, changing room, annex room, quiet room, art room, 2 bathrooms, kitchen, laundry room and outside patio. LPA Calderon inspected the men’s bathroom and tested the hot water temperature which read at 105.1 F. The women's restroom hot water temperature was measured at 114.8 Fahrenheit degrees, both restrooms were cleaned and maintained in safe and sanitary operating condition with equipment for handicapped individuals. The kitchen hot water read at 115.5 F, each client brings there own snacks from home. Kitchen used for cooking projects for the residents and staff to use with supervision. Knives were out of reach and locked. Chemicals and disinfectants were observed in the kitchen area, laundry area, and staff room area accessible to clients, not locked away and this is an immediate health risk to the clients in care. LPA Calderon observed that the smoke detectors are hardwired and carbon monoxide was operable. Last Fire Drill was conducted on 8/29/22. LPA Calderon inspected the medication storage and clients medication records. LPA Calderon observed that the clients' medication was labeled and stored in a locked cabinet which was accessible only with a key. LPA Calderon observed that the facility does not have a swimming pool or bodies of water, outside was free of debris and kept in clean and sanitary conditions.

LPA Calderon observed postage for Covid-19 preparedness and prevention, hand sanitizer and masks readily available for visitors, clients and staff. LPA observed temperature screening and log sheet in the front entrance with one central entry way. LPA Calderon used the Inspection Tool and conducted the Infection Control Domain.

Continuation page 809-C...
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SOCIAL VOCATIONAL SERVICES NORWALK INCLUSION CENTE
FACILITY NUMBER: 198601138
VISIT DATE: 10/25/2022
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The following deficiencies were observed and cited according to Code of Regulations. Title 22, Division 6, and Chapter 3, facility are being cited see LIC 809-C.

Per California Code of Regulations, Title 22, the deficiencies observed are documented on 809-D. An exit interview held. A copy of the reports and appeal rights were provided to Michelle Delgado.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/25/2022 04:45 PM - It Cannot Be Edited


Created By: Ashley Calderon On 10/25/2022 at 04:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SOCIAL VOCATIONAL SERVICES NORWALK INCLUSION CENTE
FACILITY NUMBER: 198601138

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82087(a)(3)
Buildings and Grounds
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (3) Disinfectants, cleaning solutions, poisons, and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the facility Case Manager did not comply with the section cited above with having disnfectants , cleaning solutions inaccessible to 7 out of 7 clients in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/04/2022
Plan of Correction
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Case Manager Michelle Delgado immediately placed disinfectants and chemicals in storage room locked and inaccessible to clients. Delgado and Administrator Monica Valencia will provide training to all staff and review the regulations for disinfectants (Buildings and Grounds) and send proof to LPA Calderon by POC date 11/4/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Fernando Fierros
LICENSING EVALUATOR NAME:Ashley Calderon
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022


LIC809 (FAS) - (06/04)
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