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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602097
Report Date: 02/23/2024
Date Signed: 03/06/2024 11:14:19 PM

Document Has Been Signed on 03/06/2024 11:14 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:INCLUSION SPECIALIZED PROGRAMS LLC - MANORFACILITY NUMBER:
198602097
ADMINISTRATOR:GRAHAM,DORIANFACILITY TYPE:
735
ADDRESS:13916 MANOR DRTELEPHONE:
(424) 374-4165
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY: 3CENSUS: 3DATE:
02/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:11 AM
MET WITH:Vanessa Arden, CaregiverTIME COMPLETED:
10:00 AM
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On 2/23/24 Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. 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 Vanessa walked through the kitchen and all appliances were in good working order. Knives were locked and stored in the drawer in the kitchen, medications were locked in the cabinet in the dining room and inaccessible to residents. LPA observed a 3-day supply of perishable and a 7-day supply of nonperishable foods. The water temperature measured 114.1 degrees Fahrenheit.

LPA observed the facility is clean, sanitary, and in good repair. Indoor and outdoor passageways, and other areas of potential hazard are free of obstructions. Facility temperature is between 68° degrees and 85° degrees. Areas of potential hazard are well-lit and equipped with sturdy hand railings. Carbon monoxide/Smoke detectors operate properly.

The backyard is clean and clear of obstructions and hazards and there are no bodies of water present.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

No deficiencies were cited during this visit.

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

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2024
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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