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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602097
Report Date: 02/08/2022
Date Signed: 02/08/2022 09:58:08 PM

Document Has Been Signed on 02/08/2022 09:58 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 DR #100
MONTERY PARK, CA 91754
FACILITY NAME:INCLUSION SPECIALIZED PROGRAMS LLC - MANORFACILITY NUMBER:
198602097
ADMINISTRATOR:RAFAEL CARBAJALFACILITY TYPE:
735
ADDRESS:13916 MANOR DRTELEPHONE:
(424) 374-4165
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY: 3CENSUS: 3DATE:
02/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Blanca MaciasTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Jey Cardenas conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Cardenas met with DPS staff, Margarita Olivarez and conducted a risk assessment. Based on the assessment, the facility is clear of Covid-19 infection. LPA later met with back up administrator Blanca Macias and they both toured the inside and outside grounds of the facility. LPA was properly screened for Covid-19 symptoms and temperature was checked. LPA verified that the facility has an approved mitigation plan report. The facility is licensed for three (3) ambulatory clients ages 18-59yrs old.

The one story residential house consists of (3) client bedrooms, (2) client bathrooms, family room, dining room, kitchen, laundry area, covered patio with table and chairs, and an attached garage/ storage.

During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance; visitors log with Covid-19 screening and temperature recording, PPE supplies are readily available to staff, and an additional 90-day supply of PPE was observed. Sufficient paper, cleaning, and disinfecting supplies were observed. LPA observed all staff wear a face covering. LPA observed required postings throughout the facility.

All rooms were inspected, all three (3) bedrooms all private. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed.

Client bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew, and a non-skid mat was in place. The water temperature measured at 105.0 degrees F in client bathroom. Comfortable temperature was maintained in the facility.

LPA toured the kitchen area and observed minimum two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in a locked separate areas. Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2022
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME: INCLUSION SPECIALIZED PROGRAMS LLC - MANOR
FACILITY NUMBER: 198602097
VISIT DATE: 02/08/2022
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clients in care. The First Aid kit was available and fully stocked. The facility has Fire Extinguishers available, which were checked and found to be fully charged, accessible, and inspected on 07/01/2021. There are no security bars or weapons on the premises. The fire alarm system is hardwired and connected to the Hawthorne Fire Department.

Outside grounds were toured, and no bodies of water were observed. Walkways around the home were clear of hazards. Common areas were clean and clear of hazards; doorways were free of obstructions.

No deficiencies were cited during this visit.

Advisory Notes with technical assistance were issued.

An exit interview was conducted, and a copy of this report was provided to Blanca Macias.

1. License failed to complete the N-95 Fit Testing requirement for all staff.


2. Submit Administrator designation package to LPA Cardenas
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022
LIC809 (FAS) - (06/04)
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