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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602160
Report Date: 02/24/2023
Date Signed: 02/24/2023 01:45:49 PM

Document Has Been Signed on 02/24/2023 01:45 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
GREATER LA AC/SC, 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: 106DATE:
02/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Jasmin Jimenez - Program DirectorTIME COMPLETED:
02:00 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: during the visit there were no clients in the facility, but a total of 18 consumers were at the facility in the morning. 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 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. Food is prepared at this program. The kitchen area has a refrigerator where the clients can store their snacks. Sharps are kept locked in a kitchen cabinet. The earthquake drill was last conducted on 10/20/2022 and fire/emergency disaster drill on 11/29/2022. Facility does not keep or administer medications. LPA reviewed 5 client and 5 staff files, and observed no deficiencies. Facility has 30 days supplies of Personal Protective Equipment. 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. (Continued to LIC 809C)
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SVS LAKEWOOD EAST
FACILITY NUMBER: 198602160
VISIT DATE: 02/24/2023
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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: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC809 (FAS) - (06/04)
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