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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601943
Report Date: 09/27/2024
Date Signed: 09/27/2024 03:33:15 PM

Document Has Been Signed on 09/27/2024 03:33 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:INCLUSION SPECIALIZED PROGRAMS LLC - WILCOXFACILITY NUMBER:
198601943
ADMINISTRATOR/
DIRECTOR:		RAYMUNDO LOPEZFACILITY TYPE:
735
ADDRESS:8134 WILCOX AVETELEPHONE:
(562) 447-0991
CITY:CUDAHYSTATE: CAZIP CODE:
90201
CAPACITY: 3CENSUS: 3DATE:
09/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Staff Lousia AndradeTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Staff Lousia Andrade.
The purpose of the visit is to complete the required inspection. Shortly thereafter Administrator Raymundo Lopez arrived.
LPA Trueman toured the facility along with Staff Alexandra Morales today 09/27/2024 at 1:20 PM and the following was observed:
Facility contains 3 Client Bedrooms and 3 Client Bathrooms, dining room, living room, TV room, and laundry room.
Required Annual Inspection included Infection Control, Operational Requirements, Physical Plant/ Environmental Safety, Staffing, Personnel Records/ Staff Training, Resident Records/ Incident Reports, Resident Rights/Information, Food Service, Planned Activities, Incidental Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs.
LPA observed sufficient supply of 2 day perishables and 7 day non perishables.
All staff were cleared and associated. Residents are encouraged to maintain and develop their fullest potential for independent living through participation in planned activities.
Visitation signage was posted along with signage for hand washing and proper sanitizing.
Licensee maintained an individual admission agreement for each client.
Fire Clearance has been maintained. Carbon monoxide detector was observed in the facility.
Each client has personal rights free from corporal or unusual punishment, infliction of pain, humiliation, ridicule, coercion, threats, mental abuse, or other actions of a punitive nature.
Facility was clean, safe, sanitary, and in good repair at all times for the safety and well being of residents, employees and visitors.
Medication was reviewed for 3 clients and was given per physician's directions.
3 Client Files and 6 Staff Files were reviewed.
Interviews were conducted with 2 Staff and 3 clients.
No deficiencies. Exit interview conducted.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2024
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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