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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601523
Report Date: 05/23/2023
Date Signed: 05/23/2023 12:00:01 PM

Document Has Been Signed on 05/23/2023 12:00 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:PALOMINO, SARAHFACILITY TYPE:
775
ADDRESS:5261 E WASHINGTON BLVDTELEPHONE:
(323) 318-2203
CITY:COMMERCESTATE: CAZIP CODE:
90040
CAPACITY: 45CENSUS: 18DATE:
05/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Sarah PalominoTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Glenn Trueman conducted an unannounced visit at the facility to conduct the required Annual Inspection. LPA Trueman met with Administrator Sarah Palomino and explained the reason for the visit.
The facility is an Adult Day Program (ADP) 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.
Annual Inspection includes the following Domains:
Infection Control, Physical Plant and Environment Safety, Operational Requirements, Staffing, Personnel Records- Training, Client Rights Information, Client Records- Incident Reports, Food Service, Health Related Services, Incidental Medical Services, and Disaster Preparedness..
Interviews were conducted with 3 clients and 3 staff. Files were reviewed for 5 clients and 5 staff.
All staff were cleared and associated.
Program does not administer medication for the client's.
Signage for hand washing and proper sanitizing were posted. Staff have been trained in hand washing.
Licensee kept on file client's medical assessment.
Licensee maintained an individual admission agreement for each client.
Fire Clearance has been maintained.
Facility does minimal food cooking during cooking classes 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.
Each client has personal rights free from corporal or unusual punishment, infliction of pain, humiliation, ridicule, coercion, threats, mental abuse, or other actions of a punitive nature.
Program site was clean, safe, sanitary, and in good repair at all times for the safety and well being of clients, employees and visitors. No deficiencies.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2023
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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