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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607709
Report Date: 06/17/2023
Date Signed: 06/17/2023 02:08:55 PM

Document Has Been Signed on 06/17/2023 02:08 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
Lookup Error,
, CA
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:
06/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:12 AM
MET WITH:Sabrina Swofford-Godinez TIME COMPLETED:
11:47 PM
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On 06/16/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Sabrina Swofford-Godinez. LPA explained the purpose of today’s visit. The facility is licensed to operate for (3) non-ambulatory adults ages 18-60 years of age. The residents are all Frank D. Laterman Regional Center clients.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: (3) client's' rooms, (2) bathrooms, a living area, a dining area, a kitchen, an outdoor area, an office and a garage.

LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 105.0 degrees F. A comfortable temperature of 73 degrees F. was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to clients. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. All fire extinguishers were charged. A review of the Medication Records Administration (MAR) was observed to be maintained in place.

(Evaluation Report continues on LIC 809-C)
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2023
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
Lookup Error,
, CA
FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA VALLEY HOME
FACILITY NUMBER: 197607709
VISIT DATE: 06/17/2023
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA observed First Aid Kit was maintained. A working landline phone was operational. The last fire drill was conducted on 06/07/23. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current surety bond on file.

An audit of client #1-#3 (C1-C3) service files and staff #1-#3 (S1-S3) personnel files revealed to be complete. An audit of the resident's P&I is maintained in order and complete. Interviews were conducted with (3) clients and (3) staff. The facility has the current administrators certification on file for Sabrina Godinez expiration date 08/01/23 # 6006614735

No deficiencies during this inspection visit.

An exit interview conducted with Sabrina Gondinez and copy of the report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2023
LIC809 (FAS) - (06/04)
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