198601523-4-14-2026-28-AS-ALOZ-DT5R2E-20260414123812

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601523
Report Date: 04/14/2026
Date Signed: 04/14/2026 12:38:35 PM

Document Has Been Signed on 04/14/2026 12:38 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 PROGRAM		FACILITY NUMBER:	198601523
ADMINISTRATOR/ DIRECTOR:	ISRAEL IBANEZ		FACILITY TYPE:	775
ADDRESS:	5261 E WASHINGTON BLVD		TELEPHONE:	(323) 318-2203
CITY:	COMMERCE	STATE: CA	ZIP CODE:	90040
CAPACITY: 45		CENSUS: 32	DATE:	04/14/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:36 AM
MET WITH:	Steve Montenegro, Community Supervisor		TIME VISIT/ INSPECTION COMPLETED:	12:47 PM

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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Steve Montenegro. Community supervisor and explained the reason for the visit. Paula Penduro, Site supervisor, arrived shortly after and assisted with visit. Report was read to Cecila Pantaleon over speaker phone.

The facility is licensed 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.

Infection Control: Facility maintains an infection control plan last reviewed 08/01/2023. 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 staff 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 106.9- and 108.1 -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 07/01/2025. Cleaning supplies were observed locked in a hallway cabinet. Resting area was observed with comfortable furniture (Continued on 809C)

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2026

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: 04/14/2026

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(continued from 809)
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.

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 member has a criminal background clearance. Four (4) staff files were reviewed, which include health screenings, TB test clearance, personnel records, finger clearance, and yearly training.

Client Records - Incident Reports: All client records were available for review. Files were reviewed for 4 clients, which included medical assessments, admission agreement, individual service plan or needs and care plan, and TB test. 1 of 4 clients did not have current IPP.

Client Rights - Information: Clients rights were observed posted in the activity areas. The facility staff do not use any restraints or postural supports.

Food Service: Clients' lunches were observed stored and no chemical were observed near food areas.

Health-Related Services: At least one member of 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 currently.

Disaster Preparedness: Emergency Disaster Plan LIC610D (10/03) was observed and last reviewed on 12/20/2025. Last emergency drill was conducted on 3/12/26 and are conducted monthly. Emergency supplies were observed. No deficiency noted during this visit per Title 22 Regulations, technical violations were noted. Exit interview was conducted and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2026

LIC809 (FAS) - (06/04)

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