198601231-6-13-2025-11-AS-PBUR-DHLVXL-20250613164943

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601231
Report Date: 06/13/2025
Date Signed: 06/13/2025 04:49:54 PM

Document Has Been Signed on 06/13/2025 04:49 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 II		FACILITY NUMBER:	198601231
ADMINISTRATOR/ DIRECTOR:	JOHN THOMAS PAIZIS		FACILITY TYPE:	775
ADDRESS:	231 E. SPRUCE AVE.		TELEPHONE:	(310) 674-1346
CITY:	INGLEWOOD	STATE: CA	ZIP CODE:	90301
CAPACITY: 30		CENSUS: 26	DATE:	06/13/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:50 AM
MET WITH:	Damien Hodge		TIME VISIT/ INSPECTION COMPLETED:	03:00 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 evaluation, 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 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. There are currently, 26 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 either 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. See continued LIC809-C page 2

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Pamela Bunker
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/13/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PASW II	FACILITY NUMBER: 198601231
	VISIT DATE: 06/13/2025

NARRATIVE

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Continued LIC809-C page #2

Mr. Hodge 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.

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.

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Pamela Bunker
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/13/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025

LIC809 (FAS) - (06/04)

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