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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607709
Report Date: 05/16/2022
Date Signed: 05/16/2022 03:55:00 PM

Document Has Been Signed on 05/16/2022 03:55 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 VALLEY HOMEFACILITY NUMBER:
197607709
ADMINISTRATOR:VEGA TAPIA, DANNYFACILITY TYPE:
735
ADDRESS:1217 N VALLEY STTELEPHONE:
(818) 846-0032
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY: 3CENSUS: 3DATE:
05/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:34 PM
MET WITH:Sabrina Godinez, DirectorTIME COMPLETED:
04:01 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez and Bennette Pena conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPAs were greeted by DSP Vicente Toh and Director Sabrina Godinez arrived a short time later and LPAs explained the purpose of the visit. Home is a specialize 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 a one story home located in a residential area consisting of 3 private rooms and, 2 bathrooms, living room, dining room, backyard patio area, and detached garage. The last fire drill was completed on April 11, 2022. Administrator certificate expires 08/21/2023

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 designated isolation room; as each resident has private room.
· Three (3) resident rooms, common areas, bathrooms, and outdoor physical plant was inspected.
· All client rooms were not equipped with alcohol-based hand sanitizer but available throughout the facility
· Three (3) centrally stored client medication records were reviewed.
· Staff responsible for direct care and supervision were not observed wearing masks initially but put them on shortly thereafter.
· 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 (please see 809D)
Exit interview was conducted with Director Sabrina Godinez. A copy of the report was provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2022
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 05/16/2022 03:55 PM - It Cannot Be Edited


Created By: Alberto Lopez On 05/16/2022 at 03:33 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 VALLEY HOME
FACILITY NUMBER: 197607709

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2022

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 observation LPAs and Director noticed one side wall by the back door requiring repair, a hole by gas meter needs to be filled/fixed and 3 wood platforms covering craw space entrance by back door and adjacent to gas meter need repair or replacement which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2022
Plan of Correction
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Director will reapir the wall and three platforms by POC and send photos as evidence to LPA by email.environment for residents and staff.
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: 05/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/16/2022 03:55 PM - It Cannot Be Edited


Created By: Alberto Lopez On 05/16/2022 at 03:42 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 VALLEY HOME
FACILITY NUMBER: 197607709

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.50(a)(3)
The department may deny an application for a license or may suspend or revoke a license issued under this chapter upon any of the following grounds and in the manner provided in this chapter:(3) Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California





This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation On May 16, 2022, LPA observed 1 staff were not wearing face coverings.
This poses an immediate health and safety risk to residents in care.which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2022
Plan of Correction
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 Licensee shall ensure that facility is following California Dept of Public Health and CCLD requirements. Provide a written statement stating that facility staff were re-trained and will comply with CDSS requirements and regulations, and will maintain a safe and healthful enviroment. Director will provide training to staff and send proof 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: 05/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2022


LIC809 (FAS) - (06/04)
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