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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608461
Report Date: 03/06/2025
Date Signed: 03/06/2025 04:16:44 PM

Document Has Been Signed on 03/06/2025 04:16 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 KENWOOD RESIDENCEFACILITY NUMBER:
197608461
ADMINISTRATOR/
DIRECTOR:		LOURDES MACATANGAYFACILITY TYPE:
735
ADDRESS:1930 KENWOOD STTELEPHONE:
(818) 512-2494
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY: 4CENSUS: 4DATE:
03/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:41 AM
MET WITH:Lourdes Macatangay - AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced Required - 1 Year annual inspection visit. Upon their arrival, staff on duty were Direct Care Associate 2/Tatiana Defell. LPA explained the purpose of the visit. Administrator Lourdes Macatangay arrived at 9:08 am. The program is vendorized through the Frank D. Lanterman Regional Center. The Adult Residential Facility is licensed for 4 non-ambulatory adults. Current census is four (4) non-ambulatory residents.

LPA toured the facility with the Administrator at 9:30 am and observed the following:



Required postings were observed in the office area. LPA noted the facility certificate of liability which expires on 07/01/2025. The physical plant appeared clean, sanitary and comfortable with no visible immediate hazards. There are three (3) fire extinguishers, one (1) in the kitchen, one (1) in the hallway and one (1) in the laundry room. All fire extinguishers were fully charged on 04/19/2024. Facility conducts monthly fire and safety drills, the last fire drill was conducted on 02/06/25. In addition, the facility conducts disaster/earthquake drills quarterly, the last disaster/earthquake was conducted on 01/06/2025. The dual smoke alarms and carbon monoxide detectors are hardwired and interconnected. At 10:09 am the smoke/carbon monoxide alarms were tested and observed to function properly. Facility has multiple exit doors and two (2) wheelchair accessible ramps.



(Continued on 809C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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 KENWOOD RESIDENCE
FACILITY NUMBER: 197608461
VISIT DATE: 03/06/2025
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Kitchen: There is a refrigerator, stove, dishwasher, macrowave and toaster oven in the kitchen with a breakfast nook with table/chairs. Food storage and preparation areas are clean and sanitary. Knives, cutlery and sharp kitchen objects are stored in locked kitchen cabinet. The cleaning supplies were also locked in 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 four (4). At 10:40 LPA observed six (6) cans of expired foods in the pantry and one (1) container of expired milk in the refrigerator. A citation issued on 809-D page. LPA observed an exit door on the side of the kitchen leading outside.

Laundry Room: 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. The laundry room has an exit door, leading outside.

First-Aid Kit/Medications: All medications were observed to be locked in a kitchen cabinet. In the same cabinet, LPA observed three (3) complete first-aid kits with all required supplies and the first aid manual.

Bathrooms: There are two (2) bathrooms designated for residents’ use and one (1) half bathroom for staff use. All toilets and sinks are maintained in sanitary and in operating condition. LPA observed proper grab bars, non-skid mats and covered trashcans in the bathrooms. Hot water temperature was measured at 107.4 and 108.9 degrees Fahrenheit.



Bedrooms: There are four (4) private bedrooms designated for clients' use. All of the bedrooms were properly furnished with appropriate chairs, beddings. television sets, linens with sufficient lighting. All bedrooms have exit doors leading outside to the backyard.

Continued on 809-C
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA KENWOOD RESIDENCE
FACILITY NUMBER: 197608461
VISIT DATE: 03/06/2025
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Common Areas: Include a living room, dining room and family area. A screened non-functional fireplace was observed in the living room. The common areas were properly furnished with ample sitting/tables for appropriate number of clients. Television set, karaoke machines and activities/games were observed in the family area.

Surrounding grounds: Entry/exit gates and pathways were free of obstruction. The outdoor area was free of visible immediate hazards. No bodies of water were observed at the facility. There is ample patio space for outdoor activities. There was a covered patio with furniture appropriate for outdoor use sufficient for all clients.


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.

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, deficiencies observed during the visit and citation was provided.

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

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
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Document Has Been Signed on 03/06/2025 04:16 PM - It Cannot Be Edited


Created By: Nadia Shahbazian On 03/06/2025 at 03:46 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
, 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: 03/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements: (b) The following food service requirements shall apply: (8) All food shall be of good quality...

This requirement is not met as evidenced by: Six (6) cans of non-perishable food supplies with expirations dates of 12/29/2023 and one (1) container of milk with experation date of 02/27/2025.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. Six (6) cans of non-perishable food supplies with expirations dates of 12/29/2023 and one (1) container of milk with experation date of 02/27/2025.
POC Due Date: 03/07/2025
Plan of Correction
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Correction was cleared during todays visit.
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:Eva Miller
LICENSING EVALUATOR NAME:Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2025


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