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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601573
Report Date: 04/14/2022
Date Signed: 04/14/2022 01:46:57 PM

Document Has Been Signed on 04/14/2022 01:46 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:SVS LAKEWOOD INCLUSION CENTERFACILITY NUMBER:
198601573
ADMINISTRATOR:BOBBIE NASHEDFACILITY TYPE:
775
ADDRESS:5830 LAKEWOOD BLVDTELEPHONE:
(562) 333-4070
CITY:LAKEWOODSTATE: CAZIP CODE:
90712
CAPACITY: 21CENSUS: 18DATE:
04/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Leonel Vasquez - Regional DirectorTIME COMPLETED:
02:00 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 Regional Director Leonel Vasquez and explained the reason for the visit.

The facility is an Adult Day Program (ADP) licensed to serve fifteen (15) ambulatory and six (6) non-ambulatory adults ages 18 years and above. The program consists of 1 large single-story building. A tour of the single-story building included: reception area, conference room, 2 administrator offices, break room, leisure room, art and craft room, kitchen, computer room, quiet/relaxation room, 2 storage rooms, copy room, style room, 2 restrooms, and a locker area.

LPA toured the facility with Leonel Vasquez and the following was observed: a total of 3 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 storage room. There are two fire extinguishers in total, located at each end of the hallway. All 2 of the fire extinguishers are fully charged. Facility has a wired fire system throughout the facility. There are 2 carbon monoxides in the kitchen and hallway. The restrooms were observed to be clean and have the required grab bars. The water temperature was tested, and it measured at 119 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 kept in one of the administrator offices and it is fully stocked with all required items including a current manual. Facility does not keep or administer medications. Food is not prepared at this program and clients are able to bring their own food. The kitchen area has a refrigerator where the clients can store their food. Sharps are kept locked in a cabinet inside one of the administrator offices. There are lockers for consumers in the hallway. The last fire/emergency disaster drill was conducted on 02/17/2022 and earthquake drill on 02/28/2022.

(CONTINUED TO LIC 809C)

SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2022
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: SVS LAKEWOOD INCLUSION CENTER
FACILITY NUMBER: 198601573
VISIT DATE: 04/14/2022
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LPA reviewed 4 consumer 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 hallway cabinet. 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: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
LIC809 (FAS) - (06/04)
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