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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602290
Report Date: 03/18/2022
Date Signed: 03/21/2022 12:24:38 PM

Document Has Been Signed on 03/21/2022 12:24 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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:INCLUSION SPECIALIZED PROGRAMS LLC - WEST 139THFACILITY NUMBER:
198602290
ADMINISTRATOR:RAFAEL CARBAJALFACILITY TYPE:
735
ADDRESS:4835 W 139TH STTELEPHONE:
(565) 447-0991
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY: 3CENSUS: 3DATE:
03/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:19 PM
MET WITH:Daniel Herrera GarciaTIME COMPLETED:
03:30 PM
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03/18/22, Licensing Program Analysts (LPA) Gail Johnson conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA Johnson met with the Administrator Daniel Herrera Garcia. LPA Johnson explained the purpose of today’s visit. The facility is licensed to operate and care for three (3) non-ambulatory adults (ages 18 through 59). Currently, three (3) ambulatory adult clients reside at this facility.

Facility Structure
The facility is a one-story structure located in a residential neighborhood. It consists of the following: three (3) bedrooms (no live in staff, and three client bedrooms) two (2) bathrooms, living area/family room dining area, kitchen, outdoor recreational activity area and outside patio. Bedrooms (Client rooms) Presently three (3) clients each occupy their own private bedrooms. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided. Storage for client personal belongings was observed. Physical Plant LPA Johnson toured the physical plant. There were no bodies of water or obstructions on the premises. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 110.3 degrees Fahrenheit.

Storage & Inaccessible Items
Storage areas for personal hygiene, medications, cleaning supplies, toxins, and sharp objects were stored, locked and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. Smoke detectors and carbon monoxide detectors were operable. Emergency Phone Numbers, Exit Plan, & Menu: Emergency numbers are posted and readily available for review. Facility has a land line telephone located in the kitchen (424) 269-0071. Two fire extinguishers were fully charged (located in the kitchen and in hall near backdoor exit).
Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Gail Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2022
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 2
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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: INCLUSION SPECIALIZED PROGRAMS LLC - WEST 139TH
FACILITY NUMBER: 198602290
VISIT DATE: 03/18/2022
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Infection Control
During the visit, LPA Johnson observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents. Sanitizing stations in common areas and restrooms. LPA Johnson observed staff was wearing face coverings. LPA observed the facility has a 60-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff and resident temperature logs were reviewed. The facility has a Mitigation Plan Report approved by CCLD on file.

No deficiencies were cited during this inspection visit.


An exit interview was conducted with Daniel Herrera Garcia. A copy of this report was printed and provided to Daniel Herrera Garcia.

End of report

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Gail Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
LIC809 (FAS) - (06/04)
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