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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607709
Report Date: 07/08/2025
Date Signed: 07/08/2025 04:31:17 PM

Document Has Been Signed on 07/08/2025 04:31 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:EASTER SEALS SOUTHERN CALIFORNIA VALLEY HOMEFACILITY NUMBER:
197607709
ADMINISTRATOR/
DIRECTOR:		VEGA TAPIA, DANNYFACILITY TYPE:
735
ADDRESS:1217 N VALLEY STTELEPHONE:
(818) 846-0032
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY: 3CENSUS: 3DATE:
07/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Priyanka Samarkoon-AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced Required - 1 Year annual inspection visit. LPA met with Priyanka Samarkoon-Administrator and informed her the reason for the visit. Facility is a one story house in a residential area. Facility is licensed for 3 non-ambulatory adults. Current census is three (3), one of whom is non-ambulatory. The program is vendorized through the Frank D. Lanterman Regional Center.

LPA toured the facility with the Administrator at 10:30 am and observed the following:

Required postings were observed in the office area. The physical plant appeared clean, sanitary and comfortable with no visible immediate hazards. There are two (2) fire extinguishers, one (1) in the kitchen, one (1) in the hallway near bedroom#1. Both fire extinguishers were serviced on 04/19/2025. Facility conducts monthly fire and safety drills, the last fire drill was conducted on 06/16/25. In addition, the facility conducts disaster/earthquake drills monthly, the last disaster/earthquake was conducted on 06/16/2025. The smoke alarms and carbon monoxide detectors are hardwired and interconnected. At 11:38am the smoke/carbon monoxide alarms were tested and observed to function properly. Facility is equipped with cameras at the front and backyard areas. Facility has multiple exit doors, the front entry, one in the office, one in the kitchen and one near the laundry room.

Common Areas: Include a living room and dining room. The common areas were properly furnished with ample sitting/tables for appropriate number of clients. A television set, library and activities/games were observed in the living room. LPA observed two closets in the hallway, supplied with linens and care supplies.

(Continued on 809-C)

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA VALLEY HOME
FACILITY NUMBER: 197607709
VISIT DATE: 07/08/2025
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Kitchen: There is a refrigerator, stove, dishwasher and microwave in the kitchen with a breakfast nook with table/chairs. Food storage and preparation areas are clean and sanitary. Knives and sharp kitchen objects are stored in the locked medicine cabinet. The cleaning supplies were kept locked in a cabinet underneath the sink. LPA found a sufficient supply of perishable foods (2 days) and non-perishable foods (7 days), with sufficient amount of dishes for the census of three (3).

Laundry Room: Laundry room is located near the kitchen and has an exit door, leading to the backyard. Laundry machines were observed to be functional. All laundry detergents/chemicals are stored in a locked cabinet in the laundry area, inaccessible to clients in care.

Bathrooms: There are two (2) bathrooms designated for residents’ and staff use. All toilets and sinks are maintained in sanitary and in operating condition. LPA observed proper grab bars, non-skid floors and covered trash cans in the bathrooms. Hot water temperature was measured at 107.2 and 115.7 degrees Fahrenheit.

Bedrooms: There are three (3) private bedrooms, each designed with furnishings and colors, based on each resident's taste. All of the bedrooms were properly furnished with appropriate chairs, beddings, linens with sufficient lighting. The bedrooms had walk-in closets and chest drawers. The bedrooms were clean and without any obstructions.

Surrounding grounds: No bodies of water were observed at the facility. There is ample patio space for outdoor activities. There is a covered patio with furniture, sufficient for number of clients and staff. There is a detached garage in the back, currently used for storage. The garage included a refrigerator and sofas; the facility is planning to create a movie theater area for residents' use. Surrounding area entry/exit gates and pathways were free of obstruction and hazards.

(Continued on 809-C)

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
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 VALLEY HOME
FACILITY NUMBER: 197607709
VISIT DATE: 07/08/2025
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First-Aid Kit/Medications: All medications were observed to be locked in a medicine cabinet near the dining room. In the same cabinet, LPA observed three (3) complete first-aid kits with all required supplies and the first aid manual.

Resident Files: A review of resident records to ensure compliance of licensing forms was conducted. Medications records for residents were also verified for accuracy of administration based on physician orders. P&I for the residents was counted, against receipts for accuracy of records.

Staff Files: Staff files were reviewed to ensure all forms and training certificates are up to date.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during the annual visit.

Exit Interview Conducted / A Copy of the Report provided to Administrator

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
LIC809 (FAS) - (06/04)
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