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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602929
Report Date: 06/02/2022
Date Signed: 06/02/2022 12:02:15 PM

Document Has Been Signed on 06/02/2022 12:02 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:WORK & SERVICE COALITIONFACILITY NUMBER:
198602929
ADMINISTRATOR:ARO, REYNALDOFACILITY TYPE:
775
ADDRESS:12626/12628 BELLFLOWER BLVDTELEPHONE:
(562) 401-0377
CITY:DOWNEYSTATE: CAZIP CODE:
90242
CAPACITY: 30CENSUS: DATE:
06/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Emyflair Dojillo - Operations Director TIME COMPLETED:
12:15 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 Alexis Borrero and explained the reason for the visit. Shoftly after the Operations Director Emyflair Dojillo arrived.

The facility is an Adult Day Program (ADP) licensed to serve 30 ambulatory clients. The program consists of 1 large single-story building. A tour of the single-story building included: reception area, 2 offices, 2 restrooms, kitchen, 2 activity rooms, computer lab, and storage room.

LPA toured the facility with Emyflair Dojillo and the following was observed: a total of 3 clients were at the facility during the visit. 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 storage room. There are four fire extinguishers and are fully charged. There were multiple smoke alarms throughout the facility. There is a carbon monoxide near the kitchen. The restrooms were observed to be clean and in good repair. The water temperature was tested and it measured at 110 degrees F in both restrooms, which is within the required 105-120 degrees F. The program maintains a comfortable temperature in each room/office. There are four First Aid kit and it is fully stocked with all required items including a current manual. Facility does not keep or administer medications. Food is not prepared at this program and clients are able to bring their own food. The kitchen area has a refrigerator where the clients can store their food. There are lockers for clients. The last fire/emergency disaster drill was conducted on 05/02/2022 and earthquake drill on 02/04/2022

LPA reviewed 3 consumer files to confirm emergency contact is updated and consumers have health screenings on file. LPA reviewed 3 staff records to confirm health screenings, training and fingerprint clearance.
(CONTINUED TO LIC 809C)
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: WORK & SERVICE COALITION
FACILITY NUMBER: 198602929
VISIT DATE: 06/02/2022
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Facility has 30 days supplies of Personal Protective Equipment in a reception area cabinet. 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.

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: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC809 (FAS) - (06/04)
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