197607701-5-12-2023-31-AS-MRUZ-CRRPFJ-20230512111649

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607701
Report Date: 05/12/2023
Date Signed: 05/12/2023 11:17:12 AM

Document Has Been Signed on 05/12/2023 11:17 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	EASTER SEALS SOUTHERN CALIFORNIA DEBRA HOME		FACILITY NUMBER:	197607701
ADMINISTRATOR:	VEGA TAPIA, DANNY		FACILITY TYPE:	735
ADDRESS:	10101 DEBRA AVE		TELEPHONE:	(818) 894-6938
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY: 4		CENSUS: 4	DATE:	05/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Remedios Fajardo - Distict Manager		TIME COMPLETED:	11:30 AM

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At 9:00 a.m. Licensing Program Analysts (LPAs) Melissa Ruiz and Angela Panushkina arrived at the facility to conduct an unannounced annual inspection at the facility mentioned above. LPA was greeted by Remedios Fajardo, District Manager who allowed access to the facility. The purpose of the visit was explained.

LPA conducted physical tour with the District Manager at 9:30 a.m. and observed the following:

Infection control: Staff were observed to be wearing masks. A sign in station was observed by the entrance. LPA observed trash cans throughout the facility have closed tight fitting lids.

Kitchen: LPAs toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility.The fire extinguisher was last serviced on April of 2023.

Medications: At 10:00 a.m. LPAs observed medications are centrally stored and locked in a hallway closet, along with all knives and sharps and inaccessible to clients in care. LPAs and the District Manager conducted a random medication count for one of three clients in care.

Common Areas: The facility maintains a comfortable temperature at 70°F. The living room and dining area appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility.
Bedrooms: There are four (4) bedrooms designated for clients use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens.

Bathrooms: LPAs observed appropriate grab bars and client's bathroom had non-skid mat. LPA observed appropriate hand washing signs posted in each bathroom.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA DEBRA HOME	FACILITY NUMBER: 197607701
	VISIT DATE: 05/12/2023

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Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility, they were not tested due client’s behavior episode. Staff stated they conduct various tests yearly.

The garage: Laundry service is in the attached garage and kept locked. LPAs observed all chemicals locked in a closet and inaccessible to clients in care. LPAs also observed extra PPE supplies and food storage.

Outside areas: LPAs toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients. There are no bodies of water.

Administrative: LPA collected LIC.500 and client roster.

Records: LPAs conducted records review for two out of two staff present and four out four clients in care.

No citations issued during this visit. Exit interview conducted. A copy of report was signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

LIC809 (FAS) - (06/04)

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