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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607107
Report Date: 06/21/2024
Date Signed: 06/21/2024 03:46:37 PM

Document Has Been Signed on 06/21/2024 03:46 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:EASTER SEALS SOUTHERN CALIFORNIA ONTARIO HOMEFACILITY NUMBER:
197607107
ADMINISTRATOR/
DIRECTOR:		NOTEWARE, GEORGIANNAFACILITY TYPE:
735
ADDRESS:1832 N ONTARIO STTELEPHONE:
(818) 845-1936
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY: 3CENSUS: 3DATE:
06/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Direct Support Personal (DSP's) Lesile Varas & Jackie MongoTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA), Antonia Alvizar - Ettima conducted an unannounced Required 1-year inspection at this facility at approximately 2:56 p.m. LPA was greeted by DSP's and LPA disclosed the purpose of the visit.

LPA conducted a tour of the physical plant at approximately 3:17p.m. to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

The common areas were observed for the ability to safely serve the needs clients. Living room, kitchen, dining area, three (3) bedrooms, two (2) bathrooms, detached garage with a laundry area, and outdoor areas. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to be sanitary and furnished appropriately. Clients where observed to be having snack, coloring and play board games.

Due to time constraints this required annual will be completed at a later time.

Exit interview conducted/Copy of report given
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2024
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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