<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601231
Report Date: 06/14/2024
Date Signed: 06/18/2024 12:06:14 PM

Document Has Been Signed on 06/18/2024 12:06 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:PASW IIFACILITY NUMBER:
198601231
ADMINISTRATOR/
DIRECTOR:		JOHN THOMAS PAIZISFACILITY TYPE:
775
ADDRESS:231 E. SPRUCE AVE.TELEPHONE:
(310) 674-1346
CITY:INGLEWOODSTATE: CAZIP CODE:
90301
CAPACITY: 30CENSUS: 8DATE:
06/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Chardell BrownTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced required 1- year visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the assessment, the Day Program is clear of COVID-19 infection. LPA was properly screened for COVID-19 symptoms and temperature was checked. LPA Bunker met with Director of Support Services Damien Hodge and Facility Manager/Director of Media Chardell Brown and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved mitigation plan report and infection control plan. The facility is licensed to serve (30) developmentally disabled adults, aged 18 and above. Currently, there are 8 clients present during today's visit. The facility has a 1 to 6 ratio. The Adult Day Program annual fees are current. The Day Program is vendored by Westside Regional Center.

12 Domains in the Infection Control Practices will be observed and reviewed. "I will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections."

The Adult Day Program is located in a single-story commercial business building, operating hours are 8:30 A.M. to 2:30 P.M. 5 days a week Monday through Friday. All clients bring their own lunch or bring money to purchase lunch in the community. If clients forget their lunch the facility staff will provide emergency food for clients.

Mr. Brown and LPA Bunker toured the entire Adult Day Program inside and out which consisted of the following: Talent manager's office, staff office, consumer support office, dance studio, client's locker area, client break room, two restrooms, wardrobe costume/storage room, multi-purpose room, a shared patio with a shaded area and a gated parking lot. The Adult Day Program rents 12 parking spaces next door. All areas are in compliance. See continued LIC809-C page 2
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: PASW II
FACILITY NUMBER: 198601231
VISIT DATE: 06/14/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued LIC809-C page #2

All areas of the day program were in compliance. There were no bodies of water or obstructions on the premises. Each room is adequately equipped and furnished. The programming schedules are developed by the Director and Support Staff and posted in the studios. The day program has current activity schedules, and each instructor follows, dance class, music class, and acting classes monthly plans.

The staff in-service training was reviewed. The employee personnel files and client records are in a locked cabinet in the administrative office and were reviewed and appear to be in compliance. Staff states staff was given training on dependent adult and elder abuse reporting videos. The day program currently has no clients on medications, all clients medicate at their own home. The ADP has a locked cabinet for medications. There are no personal/incidental monies handled by the day program staff.

During the visit, LPA observed the facility's infection control practices. LPA reviewed the screening protocol for visitors, staff, and clients. There are sanitizing stations in common areas and restrooms. LPA observed the facility has a 90-day supply of Personal Protective Equipment (PPE).

Documents are posted as mandated in the program activity rooms. The following Title 22 regulated areas were audited and found to be in compliance: Hot water temperature measured at 105.3 degrees Fahrenheit, carbon monoxide and smoke detectors were in compliance, fire extinguishers are fully charged, rest-rooms are clean and operational, toxic/sharp items locked inaccessible to clients. Hazardous items are inaccessible to clients and the first aid kit is fully stocked with manual. The day program grounds are free of debris/hazards.

There were no deficiencies cited.

Exit interview conducted.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2