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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607697
Report Date: 05/19/2022
Date Signed: 05/19/2022 11:22:30 AM

Document Has Been Signed on 05/19/2022 11:22 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:EASTER SEALS SOUTHERN CALIFORNIA FREDERIC HOMEFACILITY NUMBER:
197607697
ADMINISTRATOR:LOURDES MACATANGAYFACILITY TYPE:
735
ADDRESS:2740 N FREDERIC STTELEPHONE:
(818) 843-1716
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY: 3CENSUS: 3DATE:
05/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:11 AM
MET WITH:Administrator Lourdes MacatangayTIME COMPLETED:
11:33 AM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez and Ashley Calderon conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPAs met with DSP Krista Hatton and Administrator Lourdes Macatangay arrived a short time later and explained the purpose of the visit. Home is specialized home. The home has 3 ambulatory clients, none have a restricted health care condition and all clients are between the ages of 18-59. Facility is one story home located in a residential area consisting of 3 private rooms and 1 staff office, 2 bathrooms, living room, dining room, backyard patio area, and detached garage. The last fire drill was completed on April 8, 2022. Administrator certificate expires 8/04/2023

The following were observed/inspected:

· COVID-19 signs are posted at the entrance. Visitors are screened in the main entrance and a log is kept.
· Infection control signs and other COVID-19 signs are posted throughout the facility in the bathrooms, kitchen, and hallway to promote handwashing, cough/sneeze etiquette, and physical distancing.
· Facility has no designated isolation room as clients have their own room.
· Three (3) resident rooms, common areas, bathrooms, and outdoor physical plant was inspected.
· All client rooms were equipped with alcohol-based hand sanitizer and available throughout the facility
· Three (3) centrally stored client medication records were reviewed.
· Staff responsible for direct care and supervision were observed wearing masks.
· Clients were not observed wearing masks but adhering to public health social distance guidelines.
· Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
· A posted Emergency Disaster Plan was observed.
· PPE's were observed.
· Staff and resident files were not reviewed during today's visit.
· Deficiencies cited (see 809d for details)

Exit interview was conducted with Administrator Lourdes Macatangay. A copy of the report was provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2022
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 05/19/2022 11:22 AM - It Cannot Be Edited


Created By: Alberto Lopez On 05/19/2022 at 10:48 AM
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 FREDERIC HOME
FACILITY NUMBER: 197607697

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. LPA's and adminsitrator observed broken window lock on one window in resdients room.
POC Due Date: 05/26/2022
Plan of Correction
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-Adminsitrator will repair lock on window and send photo as evidence to LPA by POC date.
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. LPAs and administrator observed ripped screen in the back restroom and the front door window screen and residents bedroom screen did not properly seal the window closed.
POC Due Date: 05/26/2022
Plan of Correction
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Administrator will repair/replace the three screens and send photos as evidence by the POC due date.
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: 05/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2022


LIC809 (FAS) - (06/04)
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