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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602574
Report Date: 12/22/2022
Date Signed: 12/22/2022 12:15:14 PM

Document Has Been Signed on 12/22/2022 12:15 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-CORNISHFACILITY NUMBER:
198602574
ADMINISTRATOR:HERRERA GARCIA, DANIELFACILITY TYPE:
735
ADDRESS:12140 CORNISH AVETELEPHONE:
(562) 968-0605
CITY:LYNWOODSTATE: CAZIP CODE:
90262
CAPACITY: 4CENSUS: 3DATE:
12/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Yesica Yepez, House ManagerTIME COMPLETED:
01:00 PM
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On 12/22/2022 at 11:30am, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced annual required visit with a primary focus on infection control measures. LPA was met by Yesica Yepez, House Manager, and the purpose of today’s visit was explained. The facility is licensed to serve up to 4 non-ambulatory clients (age 18-59). There are currently (3) South Central Regional Center clients in placement. All (3) clients are ambulatory. The annual fees for the facility are current.

As part of the inspection, my primary focus was on infection control. LPA observed the facility’s infection control practices: LPA observed a sanitizing station at the facility entrance. PPE supplies are readily available to staff and residents, and additional supplies are stored. Sufficient paper, cleaning, and disinfecting supplies were observed. The facility has the mandated COVID infection control posters.


The facility is a single- story structure located in a residential neighborhood. It consists of the following: a ramp entry, three (3) bedrooms, one (1) Master bedroom with bathroom, three (3) bathrooms, living room, dining area, kitchen, staff office, laundry room. There is a back yard with a covered patio for shade with table and available chairs.

LPA Scott and Ms. Yepez toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked, except one room. That room is occupied with a client who is on quarantine for COVID-19. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. 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 118.3 F. A comfortable temperature is maintained in the facility. The last fire/earthquake drill was completed on 11/16/22.

Report continues on LIC809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2022
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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: INCLUSION SPECIALIZED PROGRAMS-CORNISH
FACILITY NUMBER: 198602574
VISIT DATE: 12/22/2022
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LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is enough perishable and non-perishable food available which is stored properly. Fire extinguishers were charged. Smoke/Carbon Monoxide detectors were operable.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations (Located in common areas and restrooms). LPA observed staff wearing face coverings and the required postings were posted throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing (www.cdss.ca.gov) for Provider Informational Notices (PIN) and for any updates relating to COVID-19 guidance.

During today’s visit there were no deficiencies observed.

Exit interview held. A copy of the report was provided to Yesica Yepez, House Manager.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022
LIC809 (FAS) - (06/04)
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