198602290-8-4-2023-11-AS-WGIS-CUDRZH-20230804132758

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602290
Report Date: 08/04/2023
Date Signed: 08/04/2023 01:28:05 PM

Document Has Been Signed on 08/04/2023 01:28 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	INCLUSION SPECIALIZED PROGRAMS LLC - WEST 139TH		FACILITY NUMBER:	198602290
ADMINISTRATOR:	RAFAEL CARBAJAL		FACILITY TYPE:	735
ADDRESS:	4835 W 139TH ST		TELEPHONE:	(565) 447-0991
CITY:	HAWTHORNE	STATE: CA	ZIP CODE:	90250
CAPACITY: 3		CENSUS: 3	DATE:	08/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	David Cook		TIME COMPLETED:	01:30 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 08/04/23, Licensing Program Analysts (LPA) Wendy Gibbs and Ruby Velasco conducted an unannounced annual required visit using the full CARE Inspection Tool. LPAs met with the Administrator David Cook, and 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 and 1 client was present during the visit. Facility Structure The facility is a single-story home located in a residential neighborhood. It consists of the following: three (3) bedrooms, two (2) bathrooms, living area/family room dining area, kitchen, outdoor recreational activity area and outside patio. Physical Plant LPAs toured the physical plant. The front and backyard were observed clean and landscaped. All walkways were clean, clear, and free of debris, hazards, and obstructions. Gates on the on the side of the home open easily from the inside. There were no bodies of water on the premises. Bedrooms (Client rooms) Presently three (3) clients each occupy their own private bedrooms. All rooms were inspected. All rooms had the required furniture including bed, dresser, nightstand, chair, and ample storage space for Client’s belongings. Beds and bedding supplies were in good condition, adequate lighting was provided. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms Bathrooms were found to be within Title 22 regulations and were clean and operational. All bathrooms had secured safety handrails and non-skid mats. LPAs observed toiletries in the bathrooms available for clients and additional supply was observed in a closet and in client’s rooms. The water temperature measured between 110.2-degrees and 110.5-degrees Fahrenheit. Kitchen LPA inspected the kitchen and observed it to be within Title 22 regulations. LPA observed all appliances, including refrigerator, stove, oven, and dishwasher to be in good repair. LPA observed an ample supply of cutleries, pots, and pans to be in good repair. All knives and sharps were secured in a locked drawer and are inaccessible to clients.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023

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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: INCLUSION SPECIALIZED PROGRAMS LLC - WEST 139TH	FACILITY NUMBER: 198602290
	VISIT DATE: 08/04/2023

NARRATIVE

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All cleaning products were secured in a locked cabinet under the sink. An additional supply is secured in locked cabinet in the laundry area. LPAs observed a 3- day supply of perishable foods and a 7-daysupply of non-perishable foods. The water temperature measured 108.3-degrees Fahrenheit.
Common Rooms LPAs, in the living room, observed a table and two (2) couches to accommodate all clients comfortably. The dining room has a rectangular table with six chairs to accommodate all clients. LPAs observed an additional table in the dining room with games and activities available for Client use. All hallways were observed clean, clear, and free of obstructions and hazards. The facility was maintained at a comfortable temperature.
Safety: LPAs observed two (2) fully charged fire extinguishers, mounted on the wall in the dining room and in the hall near the back door, last serviced on 06/19/23. The sprinkler system was last serviced on 06/19/23. The last emergency drill was conducted on 07/02/23. All exits were marked. LPAs observed all rooms have a smoke/carbon monoxide detected, that were tested and operable. When alarms went off, the fire door leading to the hallway closed automatically. LPAs inspected the First Aid Kit and found it contained the required items and a manual. The facility has a working land line telephone in the kitchen. All emergency numbers are posted and readily available for review.
Medicationa LPA observed all medications to be stored in a locked filing cabinet in the dining room. LPAs reviewed all medication for Clients and observed them to be in their original containers. LPAs reviewed the MAR and found they were consistent with distribution.
Infection Control During the visit, LPAs observed the facility's infection control practices. LPAs observed screening protocols for visitors, staff, and residents. Sanitizing stations in common areas and restrooms. LPAs observed the facility has a 60-day supply of Personal Protective Equipment (PPE). LPA observed a PPE cart in the hallwa.y 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.
Files & Interviews LPAs reviewed three (3) client files and found they contained the required documents. LPAs reviewed three (3) staff files and found they contained the required training, certification, and documents. LPAs observed the required posting throughout the facility. LPAs interviewed 1 client, who stated they were happy living at the facility and all their needs are met. LPA interviewed two (2) staff,who were knowledgeable of policy, procedure and client personal rights.

No deficiencies were observed or cited during this inspection visit.
An exit interview was conducted with Administrator, David Cook and a copy of this report was printed and provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023

LIC809 (FAS) - (06/04)

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