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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602097
Report Date: 02/17/2023
Date Signed: 02/17/2023 03:32:36 PM

Document Has Been Signed on 02/17/2023 03:32 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:INCLUSION SPECIALIZED PROGRAMS LLC - MANORFACILITY NUMBER:
198602097
ADMINISTRATOR:PANTALEON, CECILIAFACILITY TYPE:
735
ADDRESS:13916 MANOR DRTELEPHONE:
(424) 374-4165
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY: 3CENSUS: 3DATE:
02/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Vanessa ArdenTIME COMPLETED:
03:36 PM
NARRATIVE
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Licensing Program Analyst (LPA) Felisa Shirley and Licensing Program Manager (LPM) Stephanie Cifuentes 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 Shirley and LPM Cifuentes met with DSP Michael Bandele and conducted a risk assessment. Based on the assessment, the facility is clear of Covid-19 infection. LPA verified that the facility has an approved mitigation plan report. The facility is licensed for three (3) ambulatory clients ages 18-59 yrs 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. LPA Shirley and LPM Cifuentes and DSP Staff Michael toured the inside and outside grounds of the facility. All was compliant with Title 22 regulations.

LPA and LPM were properly screened for Covid-19 symptoms and temperature was checked. 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 60-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.

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.

An exit interview was conducted, and a copy of this report was provided to Vanessa Arden.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2023
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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