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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601749
Report Date: 07/21/2026
Date Signed: 07/21/2026 02:50:56 PM

Document Has Been Signed on 07/21/2026 02:50 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 INDUSTRYFACILITY NUMBER:
198601749
ADMINISTRATOR/
DIRECTOR:		ROZALIND FORDFACILITY TYPE:
775
ADDRESS:18725 E. GALE AVE.TELEPHONE:
(626) 626-4630
CITY:CITY OF INDUSTRYSTATE: CAZIP CODE:
91748
CAPACITY: 60CENSUS: 10DATE:
07/21/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Karina De La Rosa, Program DirectorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted a case management visit. LPA met with the Program Director, Karina De La Rosa, and explained the purpose of the visit.

On 6/30/26, the facility submitted the SOC341 and an incident report regarding an incident that occurred on 6/29/26. The facility reported that Staff #1 (S1) transported the participants during morning pickups and returned to the SVS program location. Upon arrival, S1 exited the vehicle and escorted the participants into the facility. After the participants were assigned to their respective groups, another staff noticed that Participant #1 (P1) was not present and immediately notified the Administrators. The administrators promptly searched the facility and surrounding areas. P1 was located inside the facility vehicle, at approximately 9:45 a.m, where participant was left unattended for approximately 20 to 25 minutes. Staff conducted a visual assessment of P1 and appeared unharmed.

During the visit today, LPA interviewed the Program Director and Staff #2 who confirmed this incident. Staff stated that the San Gabriel/Pomona Regional Center was notified and visited the site. S1 was later terminated on 7/7/26.

A deficiency is being issued today and a civil penalty is being assessed due to the absence of supervision. An exit interview was held and a copy of this report, along with appeal rights, was given to the Program Director.
Fernando Fierros
Cynthia D Chan
DATE: 07/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2026
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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Document Has Been Signed on 07/21/2026 02:50 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 07/21/2026 at 02:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SVS CITY OF INDUSTRY
FACILITY NUMBER: 198601749

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/21/2026
Section Cited
CCR
82065(a)

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82065 Personnel Requirements (a) Program personnel shall be competent to provide the services necessary to meet individual client needs...
This requirement is not met as evidenced by:

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Licensee shall conduct an in-service training regarding the procedures during morning pickups to ensure all participants are accounted for on site.

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Based on interviews and documents review, staff did not ensure that all participants is accounted for at the facility which posed an immediate health and safety risk to clients in care.
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Note: The in-service training was previously conducted and the log was given to LPA today.
***The civil penalty of $500 was issued today due to the absence of supervision.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Cynthia D Chan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2026


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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