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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606257
Report Date: 07/24/2024
Date Signed: 07/25/2024 08:21:21 AM

Document Has Been Signed on 07/25/2024 08:21 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:EASTER SEALS SOUTHERN CALIFORNIA PASO ROBLES HOUSEFACILITY NUMBER:
197606257
ADMINISTRATOR/
DIRECTOR:		LISA MARIE MCDONALDFACILITY TYPE:
735
ADDRESS:7306 PASO ROBLES AVETELEPHONE:
(818) 609-8227
CITY:VAN NUYSSTATE: CAZIP CODE:
91406
CAPACITY: 3CENSUS: DATE:
07/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:DAnny TapiaTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Valeria Conway arrived to this facility to conduct a One (1) year Required inspection. LPA met with Administrator Danny Tapia and Direct Service Professional (DSP) Juana Gomez and explained the reason for the visit. This is a specialized behavioral home vendorized by the North Los Angeles County Regional Center.

A tour of the physical plant was conducted with administrator approximately 11:20 A.M., LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. The following was noted: Facility is a single-story residence consists of three (3) resident bedrooms and three (3) bathrooms. LPA observed fully charged fire extinguishers last serviced in 04/04/2024. At 12:09 A.M., LPA tested smoke alarms and carbon monoxide detector they were all functioning properly during the time of the visit. Emergency fire drill was last conducted 02/04/2024. LPA reminded administrator that emergency drills shall be conducted at least quarterly for each shift. This facility does not have a staff room, staff are awake overnight. LPA observed required postings throughout the facility.

Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility. At 11:57 A.M. hot water was measured at 108.5 degrees Fahrenheit. Sharp objects are stored in a locked cabinet to the left of the washer and dryer. Medications, first aid and cleaning supplies were observed stored in this locked cabinet as well.

Continued on LIC 809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2024
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA PASO ROBLES HOUSE
FACILITY NUMBER: 197606257
VISIT DATE: 07/24/2024
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Continued from 809

Bedrooms: The resident bedrooms were properly furnished with at least one chair, night stand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. In addition, no bedroom was used as a passageway to another room, bath, or toilet. All rooms were free of odors. All window screens were clean and maintained in
good repair.

Bathrooms: LPA observed all bathrooms were clean, properly supplied and had functional fixtures. LPA observed grab bars and non-skid mats in all bathrooms. Residents have sufficient amounts of supplies for personal hygiene. Between 12:00 P.M. and 12:09 P.M. hot water was measured in each bathroom during physical plant tour. Hot water measured within the required limit of 105-120 degrees Fahrenheit in all bathrooms during visit.

Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. All exits have functioning auditory devices and were operational at the time of the visit. LPA observed board games and other activities stored beneath a side table next to the couch and a fireplace inaccessible to clients.



Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises. Entry/exits were free of obstruction during the time of the visit. There is a locked detached garage located on the premises, only staff is allow inside. LPA observed garage to store extra PPE supplies, medical supplies, extra furniture and cleaning supplies. LPA observed cameras around the building, no cameras inside the facility. Per administrator "Exterior cameras doesn't have audio they only record."

Continued on LIC 809-C
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA PASO ROBLES HOUSE
FACILITY NUMBER: 197606257
VISIT DATE: 07/24/2024
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Continued from LIC 809-C

Office Space: Facility has an office with two computer desks and chairs for staff use. LPA observed staff files, resident file, electronics and emergency water and food to be stored inside the closets.

Medications: Medications review began at 1:37 P.M. The medications are centrally stored in a locked cabinet next to the washer and dryer. LPA reviewed medications for the one (1) resident in care. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

Records: LPA began reviewing Personnel and Resident Records at 12:45 P.M.. One (1) resident files was reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All records appeared to be order. Three (3) personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records appeared to be in order.

LPA interviewed Staff at approximately 1:25 P.M. Resident was at a day program at the time of the visit.



During today’s visit, the LPAs obtained copies of the following: staff roster, staff schedule, and liability insurance.

No deficiencies were observed. Exit interview conducted, hard copy of this report issued to Administrator.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC809 (FAS) - (06/04)
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