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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601190
Report Date: 11/23/2021
Date Signed: 11/29/2021 11:37:14 AM

Document Has Been Signed on 11/29/2021 11:37 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:SVS CARSON INCLUSION CENTERFACILITY NUMBER:
198601190
ADMINISTRATOR:VIOLETA GUTIERREZFACILITY TYPE:
775
ADDRESS:1210 E. 223RD STREET #326TELEPHONE:
(310) 830-5679
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 21CENSUS: 8DATE:
11/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:56 PM
MET WITH:Gabriela Hernandez TIME COMPLETED:
03:59 PM
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On 11/23/21, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with the program director Gabriela Hernandez. LPA explained the purpose of today’s visit. The facility is licensed to operate for twenty-one (21) consumers of which (2) may be non-ambulatory ages 18 through 59. The consumers are Harbor Regional Center clients.

The property is located in a commercial area of Carson. Ms. Hernandez stated that there are currently eight (8) consumers for morning session and (8) for afternoon session. The morning program is from 8am -12pm and the afternoon is 1pm – 5pm. Mr. Hernancez stated that there no medication administered at this time. Currently, the program has (!) consumer with a Restricted Health Condition.

LPA and Hernandez toured the facility. The facility consists of (4) activity rooms, (1) quiet room, (1) consumer's kitchen, (1) men's restroom, (1) women's restroom, (1) sink/wash area, (4) staff offices, (1) staff break room. LPA observed the facility is clean, sanitary, and in good repair. The facility has (2) smoke detectors that were tested and operable and (2) fire extinguishers located by the office and kitchen were fully charged. LPA observed (1) carbon monoxide located in the front office area. Toxins and sharp objects were locked and inaccessible to consumer's inside breakroom.

The men's and women’s restrooms are clean and operable. The water temperature was tested and measured at 109.1 degrees Fahrenheit. The kitchen is clean and a refrigerator is available for consumers use. Food items in the refrigerator and food storage are properly stored. The day program does not provide lunch however snacks are available to consumers. First aid kit and manual are available. Walkways throughout the day program are clear of hazards and all exits are clear of debris. The facility had all the mandated posters were posted in staff break room.

Evaluation Report continues on LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/23/2021
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 DR #100
MONTERY PARK, CA 91754
FACILITY NAME: SVS CARSON INCLUSION CENTER
FACILITY NUMBER: 198601190
VISIT DATE: 11/23/2021
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and consumers, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff and resident temperature logs were reviewed.

Advisory Notes - Technical Assistance was issued, please see LIC9102-AN.

No deficiencies were cited during this inspection visit.

An exit interview was conducted and a copy of this report was provided to Gabriela Hernandez by email.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
LIC809 (FAS) - (06/04)
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