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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607107
Report Date: 06/03/2022
Date Signed: 06/03/2022 03:24:37 PM

Document Has Been Signed on 06/03/2022 03:24 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:EASTER SEALS SOUTHERN CALIFORNIA ONTARIO HOMEFACILITY NUMBER:
197607107
ADMINISTRATOR:NOTEWARE, GEORGIANNAFACILITY TYPE:
735
ADDRESS:1832 N ONTARIO STTELEPHONE:
(818) 845-1936
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY: 3CENSUS: 3DATE:
06/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:48 AM
MET WITH:Administrator Kirsten Pouri TIME COMPLETED:
03:33 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lopez conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA was met by DSP Christina Renner and Administrator Kirsten Pouri arrived a short time later and LPA explained the purpose of the visit The facility is licensed to serve 3 developmentally disabled adults ages 18- 59 During the today's visit, LPA toured the physical plant. The facility provides transportation services and is equipped with 1 van. Administrator certificate expires 11/25/2022. The last fire/disaster drill was conducted on 5/17/2022.

Physical Plant: The facility is a single story family home located in a residential neighborhood. The facility consists of a living room, kitchen, dining area, three (3) bedrooms, two (2) bathrooms, detached garage with a laundry area, and outdoor areas. Bathrooms are clean and operational. Facet in shower in bathroom #2 is leaking. Hot water temperature measured 121.1 to 123.9-degree Fahrenheit. Shower water in bathroom number 2 measured 92.6 which is not within regulation.

· Programming is in place with limited client occupancy.
· COVID-19 Infection Control screening, signs to promote hand washing, cough/sneeze etiquette, and physical distancing were observed in the entrance, common areas, hallways, and bathrooms. Facility has an approved COVID-19 mitigation plan.
· Disinfectant products are locked and inaccessible to clients.
· Restrooms have sufficient soap and posted hand washing signs.
· 3 medication records were reviewed
· Clients private rooms act as COVID-19 isolation room if needed.
· Personal Protective Equipment (PPE's) of more than 30 days were observed.
· Staff were observed wearing masks. Due to cognitive disability clients were not wearing masks.
· A posted Emergency Disaster Plan and emergency food supply and water were observed.
Deficiencies cited on 809D .
Exit interview was conducted with Administrator Kirsten Pouri. A copy of the report was provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/03/2022
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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Document Has Been Signed on 06/03/2022 03:24 PM - It Cannot Be Edited


Created By: Alberto Lopez On 06/03/2022 at 02:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA ONTARIO HOME
FACILITY NUMBER: 197607107

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation LPA and DSP Renner observed water temperture between 121.1 -123.9 degrees F in kitchen sink, two bathroom sinks and one shower. Water temperture in shower in bathroom #2 measured 92.6 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2022
Plan of Correction
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Administrator will adjust water temperture to between 105 - 120 degrees F and will send certification and photos as proof by POC datre.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stefanie Coronel
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/03/2022 03:24 PM - It Cannot Be Edited


Created By: Alberto Lopez On 06/03/2022 at 02:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA ONTARIO HOME
FACILITY NUMBER: 197607107

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation LPA and Administrator observed leaking facet in bathroom shower #1 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/10/2022
Plan of Correction
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Administrator will repair/replace facet in shower and send receipts and/or photos as proof of correction to LPA by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stefanie Coronel
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2022


LIC809 (FAS) - (06/04)
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