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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601749
Report Date: 05/11/2022
Date Signed: 05/11/2022 06:34:53 PM

Document Has Been Signed on 05/11/2022 06:34 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: 32DATE:
05/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Karina De La Rosa TIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Christine Wong conducted an unannounced annual visit at the facility. LPA met with Karina De La Rosa - Program Director and explained the reason for the visit.

Facility is licensed to served 60 adults which 54 adults ambulatory and 6 adults non-ambulatory. Facility serves an adult day program capacity and is currently serving clients virtually and partially in person due to COVID 19. Facility has a lobby/clients' lockers, a conference room, 5 staff offices, a media room, a game room, a quiet room, staff break room, kitchen/client break room, a storage room, a janitor room, art and craft room, a gym room, computer room and three unisex restrooms and one male restroom.

LPA conducted a tour of the facility with the program director and observed the following:
Restrooms water temperature were tested between 109 and 109.6 degrees F which is within the 105 - 120 degrees F. Facility has a fire sprinkle system, and 4 fire extinguishers were observed throughout the facility.
Facility's first aid kit is stored in the program director office and has required items and each group also has their own first aid kit. All the knives and sharp utensils are locked in the program director office and the cleaning supplies are stored and locked in the storage/janitor room which is inaccessible to the clients.

Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, For social distancing, each common activity room has a sign and indicated certain number of people allowed in each room, disinfecting products are available in each room and facility is disinfected every day by staff and a cleaning crew also comes every day to disinfect the whole facility. All restrooms have sufficient soap, paper towels, and hand-washing signs. PPE supplies are sufficient for more than 30 days.

No deficiencies were found during this visit. Exit interview was conducted with program Karina De La Rosa and a copy of this report was provided.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2022
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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