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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601749
Report Date: 06/13/2023
Date Signed: 06/13/2023 11:49:43 AM

Document Has Been Signed on 06/13/2023 11:49 AM - 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: 10DATE:
06/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH: Karina De La Rosa (Director)TIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Kruz Long conducted an unannounced annual inspection at the facility. 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.

LPA utilized the Compliance and Regulatory Enforcement (CARE) Tools which contain the following domains: Infection Control, Physical Plant & Environment Safety, Operational Requirements, Staffing, Personnel Reports-Training, Client Rights - Information, Client Records-Incident Report, Food Services, Health Related Services, Incidental Medical Services, Disaster Preparedness, Emergency Intervention.

The facility is located in a commercial business area 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: There is at least one person in the day program at all times, who is capable of and responsible for communicating with emergency personnel. The program site is clean, safe, sanitary and in good repair for the safety and well-being of clients, employees and visitors. Day programs is secure through the licensing agency and maintain a fire clearance approved by the city or county fire department. There is at least two persons on duty, at least one of whom is a direct care staff member, at all times when there are two or more clients in the day program. All personnel records is available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. The licensee ensures that each client's written Needs and Services Plan is updated as often as necessary. Each client have personal rights which include, but are not limited to the following: To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature. Continue to LIC809C....
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2023
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 CITY OF INDUSTRY
FACILITY NUMBER: 198601749
VISIT DATE: 06/13/2023
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 Staff responsible for providing direct care and supervision received and maintain current training in first aid and cardiopulmonary resuscitation from persons qualified by agencies including, but not limited to, the American Red Cross. Hot water temperature measured at 110.6 degrees F in the restroom. Pesticides and other similar toxic substances is not stored in food storerooms, kitchen areas, food preparation areas, or areas where kitchen equipment or utensils are stored. Disaster drills are conducted at least every six months.

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: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023
LIC809 (FAS) - (06/04)
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