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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601523
Report Date: 05/09/2024
Date Signed: 05/09/2024 10:09:08 AM

Document Has Been Signed on 05/09/2024 10:09 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:INCLUSION SERVICES ADULT DAY PROGRAMFACILITY NUMBER:
198601523
ADMINISTRATOR/
DIRECTOR:		PANTALEON, CECILIAFACILITY TYPE:
775
ADDRESS:5261 E WASHINGTON BLVDTELEPHONE:
(323) 318-2203
CITY:COMMERCESTATE: CAZIP CODE:
90040
CAPACITY: 45CENSUS: DATE:
05/09/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:32 AM
MET WITH:CECILIA PANTALEON DIRECTORTIME VISIT/
INSPECTION COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Christian Gutierrez conducted an unannounced Case Management Visit regarding incident report submitted to the department on 05/04/2024. LPA met with Cecilia Pantaleon and explained the reason for the visit.

On 05/04/2024 Staff submitted an incident report that on 05/03/2024 client #1 (C1) was hit on back in restroom by Staff #1 (S1).

During the visit LPA interviewed 3 clients, 3 staff, and S1 over phone. LPA Requested copies of personnel records, incident reports, staff training, and interviews were conducted. S1 and C1 files were obtained. Regarding incident on 5/3/2024 S1 does not have any prior history of hitting or complaints. C1 stated S1 hit her in restroom and gave her scratches. C1 stated “She was hitting me, and I was crying” She then stated she hit her in hallway not restroom. All three (3) staff that was interviewed did not recall her crying and stated she never told them anything about being hit. Facility conducted internal investigation and S1 was pulled from shift until further investigation.

At this time there is no evidence that this incident occurred. Based upon all documents reviewed from Case Management visit dated 05/09/2024, LPA did not find any health and safety concerns or deficiencies. Exit interview was conducted and a copy of this report was provided to Cecilia Pantaleon.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2024
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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