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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603103
Report Date: 03/27/2024
Date Signed: 03/27/2024 11:41:22 AM

Document Has Been Signed on 03/27/2024 11:41 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
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: 83DATE:
03/27/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:Program Director Lauren GallardoTIME COMPLETED:
12:00 PM
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On 03/27/24 Licensing program analyst (LPA) Villegas conducted an unannounced case management visit to follow up on incident that occurred on 03/15/24 and was reported to the department. LPA met with Program Director (PD) Lauren Gallardo as the purpose of todays visit was explained.

The case management visit consisted of the following: On 03/27/24 LPA obtained copies of the staff and client roster and obtained the following documents for client #1-2 (C1-C2) Facesheets, documentation of communication regarding behaviors, Harbor regional center IPPs, behavior support document for C2, and copies of incident reports regarding C1-C2. LPA also obtained copies of the following for staff #1-3 (S1-S3); zero tolerance client abuse policy, statement acknowledging requirement to report suspected abuse of dependent adults and elders, client abuse statement form, CPI training card for S2 and a copy of in-service training dated 07/31/2023. On 03/27/24 LPA interviewed PD, S2, S4, S5 and conducted interviews via telephone with C1-C2.

As part of a health and safety check LPA conducted a tour of the facility, there were no immediate health and safety concerns.

Exit interview conducted with Program Director Lauren Gallardo, and a copy of this report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2024
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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