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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601749
Report Date: 03/20/2024
Date Signed: 03/20/2024 04:10:04 PM

Document Has Been Signed on 03/20/2024 04:10 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: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: 20DATE:
03/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Karina De La RosaTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Wong 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.

1. Infection Control: Facility has an updated infection control plan in place. Facility continues to practice the infection control in the facility. Facility also has sufficient PPE supplies in the facility.

2. Physical Plant and Environmental Safety: The facility is included Client's lockers, media room, four administrative office, reception, conference room, break room for staff, game room, two office supplies room, quiet room, art room, kitchen, janitor room, three unisex bathrooms and one men bathroom, gym room, computer room and regional director office. LPA inspected the bathrooms and they are clean, sanitary and in good working condition. The hot water temperature were tested between 107.9 and 108.5 degrees F which are within the Title 22 regulation. All the cleaning supplies and chemicals are stored and locked in the janitor room. All the sharp knives and utensils are stored and locked in the program director office. The passageway and walkway are free of obstruction. The facility had a fire inspection with the city on 10/31/23 and everything is going well. The facility has a quite room for clients to rest if they do not feel good.

3. Operational Requirement: The facility is approved to serve 54 ambulatory and 6 non-ambulatory clients and currently the facility has 6 non-ambulatory clients in the facility which is within the fire clearance limit.

4. Staffing: The facility has sufficient staffing in the facility to provide care and supervision to clients in care. The staffing ratio which Regional Center required is 1:3 or 2: 6 and the facility does have the required staffing ratio.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: SVS CITY OF INDUSTRY
FACILITY NUMBER: 198601749
VISIT DATE: 03/20/2024
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5. Personnel Reports-Training: All the staff in the facility are over 18 years old and background check cleared and associated with the facility. LPA inspected three staff files and they all have required documents included: health screening, TB test result, updated first aid certificate and required training hours.

6. Client's Records-Incident Report: LPA inspected five clients files and they all have the required documents which include face sheet, admission agreement, Individual Program Plan (IPP), Physician Report and TB test result.

7. Client's right-Information: Currently the facility does not have any client required postural support.

8. Food Service: All the cleaning supplies are stored in the janitor room and all the food are stored properly in the kitchen and no toxic in the kitchen area.

9. Health Related Services: Currently the facility is managed 3 clients medication in the facility. The client's medication is centrally stored and locked in the program director office. LPA inspected 2 client's medication as one of the client brings the medication on a daily basis. They all seemed updated and accurate. All the staff have an updated first aid and CPR certificate. The facility is free of odors.

10. Incidental Medical Services: Currently no client in the facility is on any restricted health condition plan.

11. Disaster Preparedness: The facility has an updated LIC610D which dated on 5/27/23 and the last disaster drill was conducted on 01/2024 and the last fire drill was conducted on 11/29/23. The facility has two alternative shelter location.

12. Emergency Intervention: Facility staff does not use any restraints with clients.

Due to all clients left for the day program so LPA was not able to interview clients in the facility.

No deficiencies were observed during the visit.

Exit Interview conducted and A copy of the report was issued.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024
LIC809 (FAS) - (06/04)
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