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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603103
Report Date: 09/07/2023
Date Signed: 09/08/2023 09:16:36 AM

Document Has Been Signed on 09/08/2023 09:16 AM - 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:SVS-LONG BEACH WILLOW INCLUSION CENTERFACILITY NUMBER:
198603103
ADMINISTRATOR:MEREDITH GYETVAYFACILITY TYPE:
775
ADDRESS:3311 E WILLOW AVETELEPHONE:
(562) 216-5210
CITY:LONG BEACHSTATE: CAZIP CODE:
90806
CAPACITY: 21CENSUS: 11DATE:
09/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:ADMINISTRATOR LAUREN GALLARDOTIME COMPLETED:
11:30 AM
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On 09/07/2023 at 09:00 AM, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced annual inspection visit at the Social Vocational Services Long Beach Inclusion Center. LPA Calderon was allowed entry into the facility by Administrator Lauren Gallardo. Administrator Lauren Gallardo was asked questions regarding the full care tools control package (13) sections. Administrator Lauren Gallardo took LPA Calderon temperature prior to entrance into the facility. The facility is licensed for twenty-one (21) adult clients with developmental disabilities. Currently, there are eleven (11) clients in the facility with developmental disabilities.

LPA Calderon explained to Administrator Lauren Gallardo, the purpose of the one-year (1) Annual Inspection visit, and escorted LPA Calderon on a tour of the entire inside and outside facility grounds. As part of the inspection, LPA Calderon reviewed: six (6) clients service records, six (6) clients medication records, six (6) staff records. LPA Calderon interviewed six (6) clients and six (6) staff members for visit. LPA Calderon inspected the inside facility and outside grounds to include all common areas. The facilities’ last fire drill was conducted on 09/22/2023. The one-story commercial building consisting of ten (10) rooms, three (3) bathrooms, two (2) activity rooms, kitchen, gym, two (2) offices, computer room, storage room, conference room. No weapons are stored in the premises. LPA Calderon and Administrator Lauren Gallardo toured the physical plant. There is no bodies of water or firearm/ammunition on the premises. All client rooms were checked and are in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. All equipment, computers, workstations are well maintained and there is adequately PPE stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were not accessible to clients. Kitchen was inspected and observed to be clean and operational.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2023
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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SVS-LONG BEACH WILLOW INCLUSION CENTER
FACILITY NUMBER: 198603103
VISIT DATE: 09/07/2023
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A comfortable temperature was observed, and the facility has central air and heating. LPA Calderon observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 107 degrees Fahrenheit, and bathroom #2 hot water temperature properly measured at 109 degrees Fahrenheit. Kitchen hot water temperature properly measured at 114 degrees Fahrenheit. Facility two (2) carbon Monoxide and fifteen (15) Smoke Detectors hard wired and were tested and are working properly. The facility three (3) Fire Extinguishers were checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. Medications are centrally stored and in a locked storage cabinet. Facility first aid kit (1) is fully stocked with manual was checked and in order. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the building were free of debris and hazards. Outside patio accessible to clients. LPA Calderon reviewed six (6) clients files and found to be complete. LPA Calderon reviewed six (6) client’s medications and they were all found to be administered according to doctor's orders. six (6) staff files were checked and do have the required documents. The facility does NOT handle resident's money/cash resources and NO Surety bond is needed. Commercial General Liability Policy #202207644 policy period from 09/15/2022 to 09/15/2023 underwritten by Zurich American Insurance Company, coverage 1,000,000/3,000,000 is valid at time of inspection. LPA Calderon spoke to Administrator Lauren Gallardo who will email full copy of insurance contact which shows all coverages to LPA Calderon no later than 09/20/2023. All the required documents are posted in the facility in a clearly visible area to all staff, clients, and guests. LPA Calderon reviewed LIC500 and noted staff associated to facility per LIS. LPA Calderon reviewed the client’s roster, LPA Calderon confirmed clients interviewed are on client roster.
During the visit, LPA Calderon observed the facility infection control practices. LPA Calderon observed screening protocols for visitors, staff, and clients, sanitizing stations (Located in common areas and restrooms). LPA Calderon observed staff and clients were wearing face coverings, an isolation room had a posted sign and required postings throughout the facility. LPA Calderon observed the facility has a thirty-day (30) supply of Personal Protective Equipment (PPE).
LPA Calderon advised the Administrator Lauren Gallardo to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.
According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Calderon did NOT note any deficiency therefore no citation was issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Administrator Lauren Gallardo.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023
LIC809 (FAS) - (06/04)
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