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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602052
Report Date: 02/07/2024
Date Signed: 02/07/2024 08:59:48 PM

Document Has Been Signed on 02/07/2024 08:59 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:SOUTH BAY VOCATIONAL CENTERFACILITY NUMBER:
198602052
ADMINISTRATOR:COREY SYLVEFACILITY TYPE:
775
ADDRESS:21915 FIGUEROA STREETTELEPHONE:
(310) 901-4969
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 32CENSUS: 24DATE:
02/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:18 AM
MET WITH:Alexa Arechiga TIME COMPLETED:
01:59 PM
NARRATIVE
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On 02/07/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with the use of Inspection Care Tools. LPA met with the program director Alexa Arechiga. LPA explained the purpose of today’s visit. The facility is licensed to operate for thirty-two (32) consumers of which four (4) may be non-ambulatory ages 18 through 59. The consumers are Harbor Regional Center, South Central Los Angeles Regional Center and Westside Regional Center.

The property is located in a commercial area. Ms. Arechiga stated that there are currently twenty-four (24) consumers enrolled. Ms. Arechiga stated that there no medications administered at this day program.

LPA along with the program director toured the facility. The facility consists of (2) activity rooms, (1) kitchen, (1) men's restroom, (1) women's restroom, (1) handicap restroom, and (2) staff offices. LPA observed the facility is clean and sanitary. The facility has smoke detectors that were tested and operable and (2) fire extinguishers were fully charged. LPA observed (1) carbon monoxide located in the hallway area. Toxins and sharp objects were locked and inaccessible to the consumer's inside kitchen area.

The men's and women’s restrooms are clean and operable. The water temperature was tested and measured at 108.0 - 119.4 F. The kitchen is clean and a refrigerator is available for consumers' and staff use. Food items in the refrigerator and food storage are properly stored. The day program does not provide lunch, however snacks are available to consumers. A first aid kit is available. Walkways throughout the day program are clear of hazards and all exits are clear of debris. The facility had all the mandated posters posted throughout the day program. The program has an Emergency Disaster Preparedness Plan. The Fire & Earthquake drills were conducted in December 2023.

(Evaluation Report continues LIC809-C)
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2024
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 4
Document Has Been Signed on 02/07/2024 08:59 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 02/07/2024 at 12:44 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SOUTH BAY VOCATIONAL CENTER
FACILITY NUMBER: 198602052

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82066(b)(1)
Personnel Records
(b) Personnel records shall be maintained for all volunteers and shall contain the following information: (1) A health statement as specified in Section 82065(g)(1)(B).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section. LPA identified staff #1-#4 did not have a Health Screening Statement LIC 503 on filed. This violaiton which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2024
Plan of Correction
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Licensee will ensure that all staff has completed a LIC 503 Health Screening. Each personnel file should include a LIC 503 in employees files for CCLD to review/audit. License will send proof of correction by due date: 02/23/24 to: ernand.dabuet@dss.ca.gov
Type B
Section Cited
CCR
82066(b)(2)
Personnel Records
(b) Personnel records shall be maintained for all volunteers and shall contain the following information: (2) Tuberculosis test results as specified in Section 82065(g)(1)(B).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Staff #1-#4 did not have TB Test Results included in their personnel file. This violaiton which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2024
Plan of Correction
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Licensee will ensure that all staff has completed a TB Test is completed for all staff. Each personnel file should include a TB test result in employees files for CCLD to review/audit. License will send proof of correction by due date: 02/23/24 to: ernand.dabuet@dss.ca.gov
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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/07/2024 08:59 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 02/07/2024 at 12:44 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SOUTH BAY VOCATIONAL CENTER
FACILITY NUMBER: 198602052

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82066(c)
Personnel Records
(c) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Staff #5 was missing entire personnel file and was not available for CCLD to audit. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2024
Plan of Correction
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Licensee will ensure that all staff has complete file avaiable for CCLD to review/audit. Licensee will provide complete file for staff #5 for CCLD to audit. License will send proof of correction by due date: 02/23/24 to: ernand.dabuet@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024


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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: SOUTH BAY VOCATIONAL CENTER
FACILITY NUMBER: 198602052
VISIT DATE: 02/07/2024
NARRATIVE
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and consumers, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

During the visit, a review/audit of (5) client's and (5) staff files. An interview with (2) clients and (3) staff were performed. The day program is current on annual licensing fees.

There were three (3) deficiencies cited during this inspection visit when review/audit of personnel records. , (see LIC809-D)
  • Staff #1-#4 did not have the required Health Screening LIC 503
  • Staff #1-#4 did not have evidence of TB test results on file.
  • Staff #5 personnel file was not available for CCLD to review/audit


Based on interviews, observation, and record reviews the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 3,

Deficiencies are issued and an exit interview is conducted with Alexa Arechiga. Appeal rights and a copy of the report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024
LIC809 (FAS) - (06/04)
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