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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607107
Report Date: 07/23/2024
Date Signed: 07/24/2024 09:30:19 AM

Document Has Been Signed on 07/24/2024 09:30 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 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:
07/23/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:40 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
06:15 PM
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At 2:40p.m. Licensing Program Analyst (LPA) Antonia Alvizar-Ettima to continued an unannounced Required 1-Year visit to this facility. At 3:05p.m. Alexandra Morales, Direct Support Professional (DSP) and clients arrived to the facility and gained entrance. LPA discussed the purpose of this visit. At approximately 3:55p.m. Administrator, Priyanka Samarakoon joined the visit.

The facility is licensed to serve three (3) developmentally disabled adults ages 18- 59 and provides transportation services and is equipped with one (1) van. At 3:45p.m., DSP and LPA conducted a tour of physical plant inside and out. 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. Common areas were clean and appropriately furnished.

Kitchen area was clean and hazardous items (knifes, other sharp items, toxins and other chemicals) were properly secured. An adequate supply of perishable and non-perishable foods was observed to be properly stored on site.
All client bedrooms were sufficiently furnished for single occupancy, fixtures worked and no hazards were observed.

Bathrooms were sanitary, the hot water was tested between 105.5 -109.0 Fahrenheit.

The facility also contains an outdoor area, consisting of a patio and a shaded area for clients to seat. No hazardous items were observed in the yard. LPA observed washer and dryer, and both were functional in the garage and the detergent was locked in a cabinet. LPA observed a ramp in front of the facility.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 197607107
VISIT DATE: 07/23/2024
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LPA reviewed clients medication supply and medication administration records. No discrepancies were noted.
All smoke detectors were functional. Fire extinguishers were fully charged, and the facility's last fire and earth-quick drill was conducted on 07/18/2024.

At 4:15p.m. LPA Alvizar- Ettima reviewed all client files. The files observed to contain signed admission agreements, Identifying information, Medical assessment, personal rights, need and services appraisals, psychiatric evaluation report, consent forms, personal and incidental fund logs, inventory sheet for personal items and valuables, and other documents as required by the Licensing Office and Regional Center. LPA Alvizar-Ettima reviewed and discussed clients P&I records. The Administrator explained how she is safeguarding clients finances and as per explanation the Licensee is following the Title 22 Regulations.

At 4:45p.m. LPA Alvizar-Ettima reviewed the Staff files. The records contained, Personal requirements/job applications; health screenings and criminal record clearances, First Aid/CPR Certificates were current, and all training records were present.

No immediate health and safety hazard is noted during this visit. No Deficiencies cited.

Exit interview was conducted, a copy of report was issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC809 (FAS) - (06/04)
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