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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602160
Report Date: 02/27/2025
Date Signed: 02/27/2025 02:03:45 PM

Document Has Been Signed on 02/27/2025 02:03 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SVS LAKEWOOD EASTFACILITY NUMBER:
198602160
ADMINISTRATOR/
DIRECTOR:		RODRIGUEZ, ANGELAFACILITY TYPE:
775
ADDRESS:5720 BELLFLOWER BLVDTELEPHONE:
(562) 677-2093
CITY:LAKEWOODSTATE: CAZIP CODE:
90713
CAPACITY: 21CENSUS: 21DATE:
02/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:11 AM
MET WITH:Jackline Sandova, Program DirectorTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
NARRATIVE
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Licensing Program Analyst (LPA), Mayra Cota, conducted an unnanounced annual inspection today. Anacaren Garibay, Administrative Assistant, greeted LPA and Jackeline Sandoval, Program Director joined LPA thereafter. The purpose of the visit was explained and Jackline Sandoval assisted with the tour of the facility.

The facility is an Adult Day Program licensed to accommodate 21 ambulatory clients, of which 6 may be non-ambulatory. The Day Program provides services to consumers from Harbor Regional Center ages 18-59. The facility is located in a business are of Lakewood. The tour of the facility consisted of the following:

The facility has a Lobby, Conference Room, four restrooms shared by consumers and staff, seven offices which include two used by behavioral specialists and other outside service providers to consult with consumers, Style Room/Salon, Printer Room/two electrical closets, Staff Break Room/PPE and cleaning supply room, Quiet/Calming Room, Library, Computer Room, Activity/Interactive Room, Leisure Room, Art Room, Fitness Room, activity supplies storage closet, maintenance crew supply closet, kitchen, consumer backpack storage and consumer locker area.

LPA Cota, observed the following: offices and all activity rooms were observed to be clean and all walkways were free of obstructions. Furniture was in good repair and enough seating area for consumers was observed. Sufficient activity items were observed throughout the facility and were accessible to consumers. Activity calendar and schedule is posted in hallway bulletin board. Kitchen was inspected and observed to be for the ability to prepare and serve food. Two lights snacks are prepared by consumes with staff supervision at the facility, daily. The facility has sufficient emergency food supply and water. Knives were observed to be locked in a cabinet and are inaccessible to consumers. Facility is equipped with a sprinkler system. Smoke and carbon monoxide detectors were observed throughout the building. Four fire extinguishers were observed to be charged. Fire alarm panel was observed in the cleaning supply closet in the staff break room. Last fire drill was conducted on 2/23/25 and are done monthly with consumers and staff. ***Continues on LIC 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 02/27/2025 02:03 PM - It Cannot Be Edited


Created By: Mayra Cota On 02/27/2025 at 12:33 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SVS LAKEWOOD EAST
FACILITY NUMBER: 198602160

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82087(a)(3)
Buildings and Grounds
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (3) Disinfectants, cleaning solutions, poisons, and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having a trimming tool (weedwacker) in an unlocked storage room, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2025
Plan of Correction
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LPA Cota observed licensee remove the trimming tool immediately at the time of facility inspection.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Wei Siew Ho
LICENSING EVALUATOR NAME:Mayra Cota
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2025


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/27/2025 02:03 PM - It Cannot Be Edited


Created By: Mayra Cota On 02/27/2025 at 12:33 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SVS LAKEWOOD EAST
FACILITY NUMBER: 198602160

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82087(a)
Buildings and Grounds
(a) The program site 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
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Based on observation, the licensee did not comply with the section cited above by not maintaining facilty restrooms clean which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2025
Plan of Correction
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Licensee will send LPA logs, tracking cleaning dates and times for the next week, starting today. Licensee will send photos of clean floors and newly replenished trashbags for the next week.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Wei Siew Ho
LICENSING EVALUATOR NAME:Mayra Cota
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2025


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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SVS LAKEWOOD EAST
FACILITY NUMBER: 198602160
VISIT DATE: 02/27/2025
NARRATIVE
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At the time of visit, the floor in two out of the four restrooms was observed to be dirty. Trash bins in two out of the four restrooms were over-filled with soiled paper towels and other personal hygiene products. Water temperature was measured in all four bathrooms and all tested within within the required 105-120 degrees F. A trimming tool (weedwacker) was observed in an unlocked closet by the Conference Room which was discarded at the time of visit.

Eight consumer files and five staff files were reviewed during today's visit. The facility has four First Aid kits which contain all required items. First Aid replenishment items were observed to be kept in storage closet by the Conference Room.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies are being cited. See LIC 809D.

Exit interview was conducted with Jackeline Sandoval, Program Director. A copy of the report, appeal rights was issued.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025
LIC809 (FAS) - (06/04)
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