198602097-3-4-2026-11-AS-SLEO-DRV2YR-20260304164909

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602097
Report Date: 03/04/2026
Date Signed: 03/04/2026 04:49:30 PM

Document Has Been Signed on 03/04/2026 04:49 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	INCLUSION SPECIALIZED PROGRAMS LLC - MANOR		FACILITY NUMBER:	198602097
ADMINISTRATOR/ DIRECTOR:	DAISY MORENO		FACILITY TYPE:	735
ADDRESS:	13916 MANOR DR		TELEPHONE:	(424) 374-4165
CITY:	HAWTHORNE	STATE: CA	ZIP CODE:	90250
CAPACITY: 3		CENSUS: 3	DATE:	03/04/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:20 AM
MET WITH:	Administrator - Daisy Moreno		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 3/4/2026, the California Department of Social Services (CDSS) – Community Care Licensing Division (CCLD) Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with the Administrator, Daisy Moreno, and was granted entrance into the facility. LPA explained the purpose of the visit and was accompanied by staff inside and outside the facility during this inspection. This facility is licensed to serve 3 non-ambulatory adults ages 18 to 59 years old. A total of 3 clients are currently residing in this facility. The Annual Licensing Fees are current. Facility Layout: The facility is a one-story house located in a residential street. The home consists of 3 client bedrooms; 2 full bathrooms; 1 great room which consist of the kitchen, dining room area, living room area, and an office space; attached garage; laundry area; and 1 backyard patio area with a gazebo.

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Socorro Leandro
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/04/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: INCLUSION SPECIALIZED PROGRAMS LLC - MANOR	FACILITY NUMBER: 198602097
	VISIT DATE: 03/04/2026

NARRATIVE

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Outside Grounds: were toured no bodies of water were observed, walkways around the home were clear of hazards, and there are no security bars or weapons on the premises.

Kitchen Area/Facility Food: The facility has supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept inaccessible to clients in care. There is fire extinguisher in the kitchen area, and it was last serviced on 12/12/2025.

Great Room Area: There is a landline telephone and a videoconferencing device in the office area.

Client Bedrooms: 3 out of 3 client bedrooms were toured. There is adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition.

Bathrooms: Toilets, showers, and water faucets worked properly, and grab bars were secure. Adequate lighting and toiletries are accessible to clients. Water temperature measured 115.2 to 117.6 Fahrenheit. There is black mold on both showers on the tiles/grout. The vent in the small bathroom is in disrepair.

Medications: were inaccessible to clients in care. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. 3 out of 3 Medication Administration Records (MARs) were reviewed and they were current and up to date.

Garage: was toured. Backstock of cleaning supplies is stored in the garage.

Miscellaneous: Documents are posted as mandated. Last Quarterly Disaster Drill was on Fire and it was conducted on 3/1/2026. The facility has an active Surety Bond. The facility has cameras inside and outside the facility and it is included in the facility program design. The facility has egress doors in the front entrance and back exit and it is included in the facility program design. First aid kit is fully stocked. The cabinet lock above the washer machine is in disrepair.

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Socorro Leandro
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/04/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2026

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: INCLUSION SPECIALIZED PROGRAMS LLC - MANOR	FACILITY NUMBER: 198602097
	VISIT DATE: 03/04/2026

NARRATIVE

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5 staff records were reviewed, 5 out of 5 staff records had required documentation.

3 client records were reviewed and, 3 out of 3 client records had required documentation.

The facility will emailing the department the Annual Fire Inspection.

A technical advisor is being provided regarding acceptance and retention limitations.

A deficiency is being cited based on observation in accordance with the California Code of Regulations, Title 22, see LIC809D. A violation regarding the facility always being sanitary and in good repair.

An exit interview was conducted; Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Administrator, Daisy Moreno.

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Socorro Leandro
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/04/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/04/2026 04:49 PM - It Cannot Be Edited

Created By: Socorro Leandro On 03/04/2026 at 04:33 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: INCLUSION SPECIALIZED PROGRAMS LLC - MANOR	FACILITY NUMBER: 198602097
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having black mold on both bathroom shower tiles/grout and having a cabinet lock in disrepair above the washer machine, small bathroom vent is in disrepair, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/16/2026
	Plan of Correction
1 2 3 4	The Administrator has agreed to come up with a plan to maintain the facility in good repair and sanitized. The Administrator agreed to email photos of cleaned bathrooms shower tiles with the removal of black mold on the tiles/grout. The Administrator has agreed to email a video of the fixed cabinet lock above the washing machine and vent working. Email Plans of Correction to: Socorro.Leandro@dss.ca.gov

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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.

	Ulysses Coronel
NAME OF LICENSING PROGRAM MANAGER:

	Socorro Leandro
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/04/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2026

LIC809 (FAS) - (06/04)

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