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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601190
Report Date: 11/14/2024
Date Signed: 11/14/2024 02:24:55 PM

Document Has Been Signed on 11/14/2024 02:24 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:SVS CARSON INCLUSION CENTERFACILITY NUMBER:
198601190
ADMINISTRATOR/
DIRECTOR:		VIOLETA GUTIERREZFACILITY TYPE:
775
ADDRESS:1210 E. 223RD STREET #326TELEPHONE:
(310) 830-5679
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 21CENSUS: 47DATE:
11/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:41 AM
MET WITH:Gabriela Hernandez TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 11/14/24, at 12:00pm, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced visit to SVS Carson Inclusion Center (Adult Day Program). The purpose of today’s visit was to conduct the required annual inspection, using the new Care Tool. LPA was met by Program Director, Gabriela Hernandez, and the purpose of today’s visit was explained. The facility is licensed to serve twenty-one (21) developmentally disabled clients (age 18 and above), of which six (6) may be non-ambulatory. Currently, the Adult Day Program has (47) clients in the morning and (47) in the afternoon. The morning program is from 8am -12pm and the afternoon is 1pm – 5pm. The clients are Harbor Regional Center clients. The facilities’ annual fees are current.

The facility is a single-story structure located in a commercial neighborhood. It consists of the following: four (4) activity rooms, one (1) quiet room, one (1) consumer's kitchen, one (1) men's restroom, one (1) women's restroom, one (1) sink/wash area, four (4) staff offices, and one (1) staff break room.

LPA conducted a records review of (5) client records, (5) staff records, and reviewed the facility disaster plan. The facility does not handle cash resources for clients. All client & staff records were complete. The facility disaster plan was current and in compliance with Title 22 regulations at the time of visit. The current liability insurance expires on 09/15/2025.

At 12:30pm, LPA and the Program Director 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 to be 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 in the kitchen, that were fully charged. LPA observed (1) carbon monoxide located in the front office area. Toxins and sharp objects were locked and inaccessible to consumers inside break room.

Facility Evaluation Report Continued on LIC809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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: SVS CARSON INCLUSION CENTER
FACILITY NUMBER: 198601190
VISIT DATE: 11/14/2024
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The men's and women’s restrooms are clean and operable. The water temperature was tested and measured at 110.6F and 115.5-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. During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and clients. LPA observed that sanitizing stations were in common areas and restrooms. LPA observed that the facility had the required postings, posted throughout the facility. LPA further observed the facility to have a 90-day supply of Personal Protective Equipment (PPE).

LPA advised the administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing (www.cdss.ca.gov) for Provider Informational Notices (PIN) and for any updates relating to COVID-19 guidance and other related issues.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview was held, and a copy of the Facility Evaluation Report was provided to Program Director, Gabriela Hernandez.


SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC809 (FAS) - (06/04)
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