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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608461
Report Date: 12/22/2016
Date Signed: 03/09/2023 02:19:52 PM

Document Has Been Signed on 03/09/2023 02:19 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:EASTER SEALS SOUTHERN CALIFORNIA-KENWOOD RESIDENCEFACILITY NUMBER:
197608461
ADMINISTRATOR:DANNY VEGA TAPIAFACILITY TYPE:
735
ADDRESS:1930 KENWOOD STREETTELEPHONE:
(818) 512-2494
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY: 4CENSUS: DATE:
12/22/2016
TYPE OF VISIT:Annual/RequiredUNANNOUNCEDTIME BEGAN:
07:50 AM
MET WITH:Irene Gutierrez/ Danny Vega TapiaTIME COMPLETED:
10:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Patrick Shanahan conducted an Annual Required visit and inspection of the facility. LPA met with DSP, Irene Guitierrez.and administrator Danny Vega Tapia. LPA explained the reason for the visit.

A tour of the physical plant was conducted. All smoke alarms were tested and function properly. The fire extinguisher was last serviced on June of 2015 and is in need of service. The carbon monoxide detector was tested and functions properly.
Kitchen: The kitchen appeared clean and the appliances and fixtures functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives and detergents were stored in locked cabinets under the sink. Properly labeled medications were locked in an office near the living room. Bedrooms: There were five bedrooms total and 4 designated for residents' use. All bedrooms were clean, properly furnished and had sufficient lighting. Bathrooms: There were two bathrooms designated for residents' use. Both bathrooms were clean, properly supplied and had functional fixtures, however both showers were missing non-slip pads. Hot water temperature was 114 degrees Fahrenheit. Cleaning supplies were kept in locked cabinets. Common Areas: These included the living room and dining area. The common areas appeared clean and were properly furnished. Surrounding Grounds: Entry/exits were free of obstruction. The outdoor area was clean and free of hazards.

LPA reviewed files for a sample of the residents. All resident files included current medical assessments, physician orders for medications and centrally stored medication logs. Medications are given as prescribed. LPA reviewed files for staff regularly scheduled at the facility. Staff files included current first aid and CPR certifications as well as sufficient training documentation. Staff that distribute medication has appropriate training. All staff have criminal record clearance and all are associated to this facility. Staff schedule appears sufficient to meet the needs of residents.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.
SUPERVISORS NAME: Maryjo Schnitzer
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2016
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 03/09/2023 02:19 PM - It Cannot Be Edited


Created By: Patrick Shanahan On 12/22/2016 at 09:21 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA-KENWOOD RESIDENCE
FACILITY NUMBER: 197608461

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2016
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/02/2017
Section Cited
80087(a)
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80087(a) Buildings and Grounds. The facility shall be kept clean, sanitary and in good repair at all times.

LPA noticed that the fire extinguisher is in need of service
Type B
01/02/2017
Section Cited
80087(b)
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80087(b) Buildings and Grounds. Facilities shall use protective devices including but not limited to nonslip material on rugs.

LPA observed no non slip pads for showers in both bathrooms
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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:Maryjo Schnitzer
LICENSING EVALUATOR NAME:Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2016
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2016


LIC809 (FAS) - (06/04)
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