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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602160
Report Date: 03/14/2022
Date Signed: 03/14/2022 12:27:50 PM

Document Has Been Signed on 03/14/2022 12:27 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SVS LAKEWOOD EASTFACILITY NUMBER:
198602160
ADMINISTRATOR:RODRIGUEZ, ANGELAFACILITY TYPE:
775
ADDRESS:5720 BELLFLOWER BLVDTELEPHONE:
(562) 677-2093
CITY:LAKEWOODSTATE: CAZIP CODE:
90713
CAPACITY: 21CENSUS: 9DATE:
03/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Jasmin Jimenez - Program DirectorTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility with focus on the infection control domain, medication and food review. LPA Mora met with Program Director Jasmin Jimenez and explained the reason for the visit.

The facility is an Adult Day Program (ADP) licensed to accommodate 21 ambulatory clients of which 6 may be non-ambulatory, in the age range of 18 and over. The program consists of 1 large single-story building. A tour of the single-story building included: reception area, conference room, 2 case managers offices, program directors office, 3 staff offices, travel office, leisure room, fitness room, kitchen, computer lab, quiet/relaxation room, locked storage cabinets, 2 storage rooms, janitor closet, copy room, style room, arts and crafts room, 4 restrooms, and a locker area.

LPA toured the facility with Jasmin Jimenez and the following was observed: a total of 9 clients were at the facility during the visit. The staff to client ratio is 1:3. The program site is clean, safe, sanitary and in good repair. All passageways are free from obstruction. Disinfectants, cleaning solutions and poisons are inaccessible to clients and are locked inside a janitor’s closet. There are three fire extinguishers in total, located in the reception area, kitchen and hallway. All 3 fire extinguishers are fully charged. Facility has a wired fire system throughout the facility. The restrooms are well maintained and in good repair. The water temperature was tested, and it measured at 105.3 degrees F, which is within the required 105-120 degrees F. The First Aid kit is kept in one of the case manager’s office room and it is fully stocked with all required items including a current manual. Facility does not keep or administer medications. Food is not prepared at this program and clients are able to bring their own food. The kitchen area has a refrigerator where the clients can store their food. Sharps are kept locked in a kitchen cabinet. Client and staff files were not reviewed in today’s visit. The last fire/emergency disaster drills were conducted on 01/06/2022 and 02/28/2022.

(CONTINUED TO LIC 809C)

SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2022
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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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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SVS LAKEWOOD EAST
FACILITY NUMBER: 198602160
VISIT DATE: 03/14/2022
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Facility has 30 days supplies of Personal Protective Equipment in the Program Director’s office room. Facility is following COVID-19 recommendations regarding screening visitors, staff, and clients. Covid-19 prevention signs are posted throughout the facility and hand-washing signs were observed in the bathrooms. Sufficient hand soap, hand sanitizer, and paper towels were observed.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
LIC809 (FAS) - (06/04)
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