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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601749
Report Date: 10/27/2021
Date Signed: 10/27/2021 03:46:19 PM

Document Has Been Signed on 10/27/2021 03:46 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 CITY OF INDUSTRYFACILITY NUMBER:
198601749
ADMINISTRATOR:ROZALIND FORDFACILITY TYPE:
775
ADDRESS:18725 E. GALE AVE.TELEPHONE:
(626) 626-4630
CITY:CITY OF INDUSTRYSTATE: CAZIP CODE:
91748
CAPACITY: 60CENSUS: 60DATE:
10/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Karina De La Rosa (Director)TIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Kruz Long conducted an unannounced annual inspection at the facility. Upon arrival, LPA met with Karina De La Rosa (Director) and explained the purpose of the visit. The facility is licensed to serve sixty (60) Developmentally Disabled (54 Ambulatory and 6 Non-Ambulatory clients).

The single story facility is located in a commercial business which contains the following: Reception area, 4 offices, conference room, staff room, 4 program rooms (exercise, art, media, library), computer room, break room/kitchen, copy area, storage room, janitor room, 4 restrooms, server room and a quiet room.

During today's inspection, LPA observed the following: Licensee is not operating beyond the conditions and limitations specified on the license, including the capacity limitation. Motor vehicles used to transport clients is maintained in a safe operating condition. All clients are protected against hazards within the program site. Disinfectants, cleaning solutions, poisons are locked the janitor's room inaccessible to clients. The licensee provides a separate room for use by ill client. Hot water temperature measured at 105 degrees F in the restroom. All toilets and hand washing basin is maintained in a safe, sanitary, operating condition. Additional equipment for the physically handicapped is provided. Clients in care for less than 8 hours is provided snacks. The licensee does provide care and supervision necessary to meet the client's needs and all services specified in the admission agreement. The licensee ensures that clients are kept clean and dry and the day program remains free of odors. Program personnel is sufficient in numbers to provide the services necessary to meet individual client needs. The written Needs and Services Plan is maintained in the client's file. Staff subject to a criminal record has a clearance. Disaster drills was conducted and documented at least every 6 months. Staff responsible for direct care and supervision have current First Aid and CPR. The administrator is at the program site the number of hours necessary to manage and administer the program.

No deficiencies were observed during today's visit.
An exit interview was conducted with Karina De La Rosa and a copy of this report provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2021
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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