198601749-4-23-2026-28-AS-CDCN-DTER92-20260423124849

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601749
Report Date: 04/23/2026
Date Signed: 04/23/2026 12:49:03 PM

Document Has Been Signed on 04/23/2026 12:49 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	SVS CITY OF INDUSTRY		FACILITY NUMBER:	198601749
ADMINISTRATOR/ DIRECTOR:	ROZALIND FORD		FACILITY TYPE:	775
ADDRESS:	18725 E. GALE AVE.		TELEPHONE:	(626) 626-4630
CITY:	CITY OF INDUSTRY	STATE: CA	ZIP CODE:	91748
CAPACITY: 60		CENSUS: 12	DATE:	04/23/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:09 AM
MET WITH:	Yvette Sanchez, Case Manager		TIME VISIT/ INSPECTION COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection. LPA met with the Case Manager, Yvette Sanchez, and explained the reason for the visit. The day program is licensed for 60 clients, ages 18-59, of which 6 may be non-ambulatory. LPA toured the facility and inspected/observed the following using the Compliance and Regulatory Enforcement (CARE) tools. Infection Control: The facility has sufficient supplies of PPE and utilizing gloves when necessary to assist the participants.. They are performing proper hand hygiene. Staff are cleaning and disinfecting surfaces regularly to keep the facility clean. Physical Plant & Environmental Safety: The facility consists of the following: reception area, conference room, lockers, five (5) staff offices, four (4) restrooms, staff lounge, computer/library room, Media Room, Quiet Room, copy machine area, Art Room, kitchen, janitor's room, electrical room, exercise room, and two (2) storage rooms. The hot water temperature is measured within the required range of 105 - 120 degrees F. Knives and cleaning supplies are locked and inaccessible to participants. Operational Requirements: The facility is operating within the approved fire clearance. Staffing: The staffing is maintained at a 1 staff to 3 client ratio. Personnel Records - Training: LPA reviewed 6 Staff records and they have the required documentation in their files. The CPR/First aid certificates are current. Client Records - Incident Reports: LPA reviewed 5 Client records and files consist of the admission agreement, medical assessment with TB test result, consent forms, and current IPP or ISP.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/23/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SVS CITY OF INDUSTRY	FACILITY NUMBER: 198601749
	VISIT DATE: 04/23/2026

NARRATIVE

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Client Rights - Information: There are no clients utilizing any postural supports.
Food Service: Clients bring their own lunch and snacks daily. Facility has extra snacks available. Health-Related Services: LPA reviewed 2 client medications and they are given their medications as prescribed. The medications are individually kept in a locked box.
Incidental Medical Services: There is one individual with a restricted health condition, and the plan is renewed annually. Staff received training on the health plan..
Disaster Preparedness: Facility has the updated LIC610D form and is conducting monthly emergency drills. Emergency Intervention: Staff do not utilize manual restraints at the site.

There are no deficiencies observed. A copy of this report was given to the Program Director.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/23/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2026

LIC809 (FAS) - (06/04)

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