198601943-11-27-2023-28-AS-THEA-CXYUYW-20231127150038

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601943
Report Date: 11/27/2023
Date Signed: 11/27/2023 03:00:46 PM

Document Has Been Signed on 11/27/2023 03:00 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:	INCLUSION SPECIALIZED PROGRAMS LLC - WILCOX		FACILITY NUMBER:	198601943
ADMINISTRATOR:	JUAN RAMIREZ		FACILITY TYPE:	735
ADDRESS:	8134 WILCOX AVE		TELEPHONE:	(562) 447-0991
CITY:	CUDAHY	STATE: CA	ZIP CODE:	90201
CAPACITY: 3		CENSUS: 3	DATE:	11/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Amiya Turner - DSP		TIME COMPLETED:	03:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Tena Herrera conducted the required unannounced annual inspection. LPA was greeted by Amiya Turner (Caregiver) and Raymundo Lopez (Administrator) who later assisted with the visit, the reason for today’s visit was explained. The facility is licensed to serve 4 ambulatory clients (3 of which may be non-ambulatory) ages 18-59. Facility currently has 3 clients serviced by South Central Los Angeles Regional Center.

The facility is a single-story home located in a residential area in Cudahy, Ca. A tour of the facility includes: living room, dining area, kitchen, laundry area, 2 bathrooms, 1 1/2 bathroom, 3 client bedrooms, detached garage, front yard and back yard.

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan.

Physical Plant & Environment Safety: Smoke detectors and carbon monoxide detectors are operable and in compliance. Bathrooms are clean and operational. Client bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available to the clients. The hot water temperature was tested in client bathrooms and measured between 111.9 – 115.7 degrees F which is within the required range of 105-120 degrees F. Storage areas for cleaning solutions, toxins, knives, and hazardous items were observed to have a locked area for storage, however, during today's visit LPA observed a cleaning disinfectant stored in an unlocked cabinet within the 1/2 bathroom (details will be cited on the 809-D). The fire extinguisher was observed and is fully charged.
Operational Requirements: The facility maintains the required fire clearance and plan of operation on file. Facility conducts emergency/fire/earthquake drills regularly, last drill was on 10/19/23. The facility ensures that clients are given the opportunity to participate in community activities and there is a shaded outdoor activity area available. (Continued on 809-C)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: INCLUSION SPECIALIZED PROGRAMS LLC - WILCOX	FACILITY NUMBER: 198601943
	VISIT DATE: 11/27/2023

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Staffing: There appears to be sufficient staffing at all times in the facility with at least one CPR trained employee on the premises at all times. Administrator Raymundo Lopez certificate expires 2/19/2024.
Personnel Records-Training: Staff has criminal record clearance, current First-Aid/CPR/AED/CPI training, and ongoing training. Staff files are maintained at the facility and kept in a secure location. During today’s visit LPA reviewed 5 staff files with no issues.
Client Rights-Information: Facility provides clients with telephone and internet.
Client Records-Incident Reports: Client files are kept in a secure location and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. LPA reviewed 3 client files during today’s visit with no issues.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Services: All medications for clients are kept locked and inaccessible to other clients. Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers. During the visit today, LPA reviewed 3 Client Medications with no issues.
Incidental Medical & Dental: All training for staff who assist clients with restricted health conditions is documented in the facility personnel files and performance is reviewed annually.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Last emergency/fire drill was conducted on 10/19/2023.
Emergency Intervention: Clients at this facility do not have restraints nor do they require the use de-escalation techniques. However, staff do maintain their CPI certificates in the case that manual restraint is needed, and understand documentation and reporting procedures.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency cited during todays visit is documented on the 9099-D..

Exit interview was held and a copy of the report and appeal rights were provided to Administrator Raymundo Lopez.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/27/2023 03:00 PM - It Cannot Be Edited

Created By: Tena Herrera On 11/27/2023 at 02:32 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: INCLUSION SPECIALIZED PROGRAMS LLC - WILCOX	FACILITY NUMBER: 198601943
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)

Building and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as during facility tour LPA observed a cleaning disinfectant containing bleach to be in an unlocked cabinet under the sink in the 1/2 bathroom, there were clients in care at the facility during observation, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/28/2023
	Plan of Correction
1 2 3 4	Staff immediatly removed cleaning disinfectant and properly stored it with all other cleaning supplies in locked kitchen cabinet during visit Administrator to ensure that all storage areas for disinfectants, cleaning solutions, and poisons shall be locked at all times and will provide training to all staff regarding the storage of the disinfectants, cleaning solutions and poisons. A copy of the staff attendance log and copy of the training material will be emailed to LPA by 12/11/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

David Sicairos

LICENSING EVALUATOR NAME:

Tena Herrera

LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

LIC809 (FAS) - (06/04)

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