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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601523
Report Date: 04/24/2025
Date Signed: 04/24/2025 01:59:43 PM

Document Has Been Signed on 04/24/2025 01:59 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
GREATER LA AC/SC, 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: 29DATE:
04/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:39 AM
MET WITH:Paula Panduro - Program SupervisorTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Paula Panduro and explained the reason for the visit.

The facility is licensed to as an Adult Day Program to serve 45 developmentally disabled clients ages 18 - 65 years old, of which 10 may be non-ambulatory. The facility is located in a commercial area and consist of the following: a fitness room, common area, a staff room, a relaxation room, an arts and crafts room, a game room, a changing room, female and male locker rooms, music room, a vocational room, an emergency supply room, a supply room, a kitchen, female and male restrooms, communication room, two (2) computer rooms, (3) offices, several storage areas, and outdoor area.

The following CARE tool domains were reviewed during this visit:

Infection Control: Facility maintains an infection control plan last reviewed 2/3/25. Hand sanitizing and infection prevention were observed at the facility. A responsible person was available at the facility.

Physical Plant & Environmental Safety: LPA toured the facility with Paula Panduro and observed the facility is clean and in good repair indoor and outdoor. Each activity room is supplied with furniture and the needed materials for activities. Two (2) restrooms (male/female) were observed in good repair and water temperature was tested between 105.0 and 105.2 degrees F., which is within the required 105-120 degrees F. Smoke/Carbon Monoxide detectors were tested and are in working condition. Fire extinguishers were observed last checked on 7/26/24. Cleaning supplies were observed locked in a hallway cabinet. Sharps were observed locked in kitchen area. Resting area was observed with comfortable furniture. Facility provides drinking water to the clients. Passageways and exit areas were observed free of obstructions. Canopies are provided during outdoor activities to provide shade. No large bodies of water were observed.(CONT.LIC809C

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2025
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: INCLUSION SERVICES ADULT DAY PROGRAM
FACILITY NUMBER: 198601523
VISIT DATE: 04/24/2025
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Operational Requirements: Facility has a fire clearance and poster for reporting requirements were observed.
Staffing: Sufficient staffing was observed with clients. Facility vendorized with South Central Los Angeles and East Los Angeles Regional Center and maintain a ratio of 3:1.
Personnel Records - Training: All staff records were available for review. Each staff has a criminal background clearance. Five staff files were reviewed which include health screenings, TB test clearance, personnel records, finger clearance, and yearly training. Program Administrator ...
Client Records - Incident Reports: All client records were available for review. Files were reviewed for 5 clients, which included medical assessments, admission agreement, individual service plan or needs and care plan, and TB test. 3 out of 5 clients did not have a medical assessment and 1 of the 3 did not have a TB test clearance on file.
Client Rights - Information: Clients rights were observed posted in the activity areas. The facility staff do not use any restrains or postural supports.
Food Service: Clients' lunches were observed stored and no chemical were observed near food areas.
Health-Related Services: At least one staff has a current CPR/First Aid certificate. Facility staff do not assist with medications.
Incidental Medical Services: Facility does not provide services to any clients with restricted health conditions at this time.
Disaster Preparedness: Emergency Disaster Plan LIC610D(10/03) was observed and last reviewed on 12/28/24. Last emergency drill was conducted on 3/21/25 and are conducted monthly. Emergency supplies were observed.

LPA interviewed 4 clients and 4 staff.

Deficiencies were noted during this visit per Title 22 Regulations and a technical violation was noted.

Exit interview was conducted with Cecilia Pantaleon and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/24/2025 01:59 PM - It Cannot Be Edited


Created By: Mary G Flores On 04/24/2025 at 01:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: INCLUSION SERVICES ADULT DAY PROGRAM
FACILITY NUMBER: 198601523

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068.2(f)(1)(B)
Needs and Services Plan
(f) The completed Needs and Services Plan shall include: (1) The client's desires and background and formal supports, obtained from the client's family or his/her authorized representative, if any, regarding the following: (B) A written medical assessment including primary physician, health problems and medical history, prescribed medications and their strength, quantity, frequency required and purpose as specified in Section 82069(b)(3).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 5 clients do not have a medical assessment in file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2025
Plan of Correction
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Administrator will obtain medical assessment for C1, C4, and C5 and will submit a copy to the department by POC due date 5/2/25.
Type B
Section Cited
CCR
82069(b)(1)
Client Medical Assessments
(b) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 5 clients, C1 does not have a TB test clearance on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2025
Plan of Correction
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Administrator will submit a copy of TB test clearance to the department by POC due date 5/2/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Tony Vasallo
NAME OF LICENSING PROGRAM MANAGER:
Mary G Flores
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2025


LIC809 (FAS) - (06/04)
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