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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601523
Report Date: 06/02/2022
Date Signed: 06/02/2022 01:53:11 PM

Document Has Been Signed on 06/02/2022 01:53 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:INCLUSION SERVICES ADULT DAY PROGRAMFACILITY NUMBER:
198601523
ADMINISTRATOR:IBANEZ, ISRAELFACILITY TYPE:
775
ADDRESS:5261 E WASHINGTON BLVDTELEPHONE:
(323) 318-2203
CITY:COMMERCESTATE: CAZIP CODE:
90040
CAPACITY: 45CENSUS: 40DATE:
06/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Cecilia Pantaleon - Program Director TIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility with focus on the infection control domain, medication and food review. LPA Mora met with Program Director Cecilia Pantaleon and explained the reason for the visit.

The facility is an Adult Day Program (ADP) licensed to serve licensed to serve 45 developmentally disabled clients ages 18-65, in which ten may be non-ambulatory. A tour of the single-story building included: reception area, fitness/theater room, storage room, 3 offices, conference room, men's restroom, women's restroom, kitchen, staffing room, 2 computer rooms, communication resource lab, 2 recreational/training room, music training room, pre-vocational training room, emergency supply room, women's locker room, men's locker room, changing room, relaxation room, and leisure and eating area.

LPA toured the facility with Cecilia Pantaleon and the following was observed: a total of 12 clients were at the facility during the visit. The staff to client ratio is 1:3. The program site is clean, safe, sanitary and in good repair. All passageways are free from obstruction. Disinfectants, cleaning solutions and poisons are inaccessible to clients and are locked inside a hallway closet. There are six fire extinguishers and are fully charged. There were multiple smoke alarms throughout the facility. There is a carbon monoxide near the entrance. The restrooms were observed to be clean and have the required hand bars for non-ambulatory clients. The water temperature was tested and it measured at 109.8 degrees F in both restrooms, which is within the required 105-120 degrees F. The program maintains a comfortable temperature in each room/office. The First Aid kit is fully stocked with all required items including a current manual. Facility does not keep or administer medications. Facility does minimal food cooking and clients are able to bring their own food. Sharps are kept locked inside one of the offices. The kitchen area has a refrigerator where the clients can store their food. There are lockers for clients. The last fire/emergency disaster drill and earthquake drill were conducted on 02/10/2022.
(CONTINUED TO LIC 809C)
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2022
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: INCLUSION SERVICES ADULT DAY PROGRAM
FACILITY NUMBER: 198601523
VISIT DATE: 06/02/2022
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LPA reviewed 4 client files to confirm emergency contact is updated and consumers have health screenings on file. LPA reviewed 4 staff records to confirm health screenings, training and fingerprint clearances.

Facility has 30 days supplies of Personal Protective Equipment in the staffing room. Facility is following COVID-19 recommendations regarding screening visitors, staff, and clients. Covid-19 prevention signs are posted throughout the facility and hand-washing signs were observed in the bathrooms. Sufficient hand soap, hand sanitizer, and paper towels were observed.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.

SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC809 (FAS) - (06/04)
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