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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609056
Report Date: 05/21/2024
Date Signed: 05/24/2024 01:49:52 PM

Document Has Been Signed on 05/24/2024 01:49 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:EASTER SEALS SOUTHERN CALIFORNIA VAN NUYSFACILITY NUMBER:
197609056
ADMINISTRATOR/
DIRECTOR:		FERNANDEZ, CYNTHIAFACILITY TYPE:
775
ADDRESS:16605 SHERMAN WAYTELEPHONE:
(818) 388-7428
CITY:VAN NUYSSTATE: CAZIP CODE:
91406
CAPACITY: 50CENSUS: 30DATE:
05/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Cynthia FernandezTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Valeria Conway and Martha Arroyo conducted an unannounced required annual. Upon arrival LPAs met with Program Supervisor Mayda Soto and explained the reason for the visit. Shortly after Program Director Cynthia Fernandez joined the visit. At the time of the visit all participants except one left to outings in the community.

At 10:40 am LPAs and Program Supervisor toured the physical plant areas inside and outside ensuring that there are no health and safety hazards, and the facility is in compliance with Title 22 Regulations.

The facility has two (2) kitchens for participant and staff used. LPAs observed the first kitchen by the entrance. LPA’s observed a kitchen sink, kitchen cabinet and a refrigerator. At 10:47 am the hot water temperature was measured at 112.6 degrees Fahrenheit. Refrigerator contains participant’s lunch, snacks, and drinks. Participants will provide own lunch. There is a storage/pantry room that is permanently locked and inaccessible to participants unless there is a staff member with them. Inside storage/pantry room LPA’s observed paper plates, and adequate supplies of Personal Protection Equipment (PPE), emergency food, emergency water, sharp objects, cleaning supplies, blankets, flashlights, emergency backpacks and extra first aid kits. LPA’s observed a second kitchen. The hot water temperature was measured at 111.7 degrees Fahrenheit. At 11:05 am, LPA’s observed a roof access ladder accessible to participants. LPAs also observed missing and water damaged ceiling tiles in kitchen #1, kitchen #2 and electrical room during the inspection.

Continued on LIC 809-C
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE: DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 05/24/2024 01:49 PM - It Cannot Be Edited


Created By: Valeria Conway On 05/21/2024 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA VAN NUYS
FACILITY NUMBER: 197609056

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82019(e)(3)
Criminal Record Clearance
(e) Prior to working, residing or volunteering in a licensed day program, all individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall do the following: (3) Request the licensee or applicant for a license to request a transfer of a criminal record clearance as specified in Section 82019(f); or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as S1 has finger print background clearance but is not associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/21/2024
Plan of Correction
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Program Director will associate S1 to the facility and send proof to LPA before POC due date. POC has been met. During the inspection S1 was associated to the facility.
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:Desaree Perera
LICENSING EVALUATOR NAME:Valeria Conway
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/24/2024 01:49 PM - It Cannot Be Edited


Created By: Valeria Conway On 05/21/2024 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA VAN NUYS
FACILITY NUMBER: 197609056

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82087(a)
Buildings and Grounds
(a) The program site 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 LPAs observation, the licensee did not comply with the section cited above in as 3 rooms had stained carpets, women's bathroom sink was leaking and multiple missing and demaged ciling tiles in both kitchens and electrical room which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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Program Director will have ceiling tile replaced. Women's bathroom sink serviced. Facility shall have carpet cleaned and send proof to LPA before due date.
Type B
Section Cited
CCR
82068.2(d)(1)
Needs and Services Plan
(d) If the client has an existing needs appraisal or individual program plan (IPP) completed by a placement agency, or a consultant for the placement agency, the Department may consider the plan to meet the requirements of this section provided that: (1) The needs appraisal or IPP is not more than one year old.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above as two out of seven participants files were missing updated IPPs which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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Program Director will provide copy of current IPPs to LPA before POC due date
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:Desaree Perera
LICENSING EVALUATOR NAME:Valeria Conway
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024


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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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA VAN NUYS
FACILITY NUMBER: 197609056
VISIT DATE: 05/21/2024
NARRATIVE
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Continued from LIC 809

Restrooms: There are six restrooms in the facility. Restrooms were observed to be clean and sanitary. Five (5) out of six (6) restrooms were in operating condition. At 10:51 am LPA’s observed water leaking from under the women’s restroom sink. LPA’s observed a sufficient amount of soap and paper products in each restroom, as well as hand washing posters. Between 10:50 am and 11:10 am hot water temperature was measured in all restrooms, and they measured between 112.4 – 115.9 degrees Fahrenheit during the time of the inspection.

Common Areas: Between 10:59 am and 11:01 am, LPAs observed stained carpet in the movie room, relax room and conference room. At the time of the visit, common seating area and office furniture were observed to be in good condition. LPA observed the required postings throughout the facility. Fire extinguishers were observed to be fully charged and last serviced on 06/05/2023. LPAs advice staff to have fire extinguishers serviced soon. At 11:13 am, smoke detector and carbon monoxide detector were tested and operational. At 11:30 am, the emergency pull system was tested and operational. LPAs observed board games, movie films and coloring books for participants. LPAs observed a shaded patio area for participant use. The facility is fully gated. LPAs observed gates to be open at the time of the visit. LPAs did not observe any obstructions to exits at this time.

At approximately 12:30 pm, records review began. Seven (7) participant’s records were reviewed. LPAs observed two (2) out of seven (7) participant’s files did not have an updated Individual Program Plan (IPP). Seven (7) personnel records were reviewed. Record review and interview conducted revealed Staff #1 (S1) was employed by the company in 2014 and transferred to this location about a year ago. LPAs reviewed the facility guardian roster and discovered that S1 does have fingerprint background clearance but is not associated to this facility.


LPAs obtained copies of the following documents during the inspection: Current liability Insurance, Infection Control Plan, Participant Roster, and Personnel Report. Last emergency disaster plan was conducted on 04/24/2024 and last emergency drill was conducted on 03/21/2024.

Continued on LIC 809-C
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024
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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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA VAN NUYS
FACILITY NUMBER: 197609056
VISIT DATE: 05/21/2024
NARRATIVE
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Continued from LIC 809-C

Per the California Code of Regulations, Title 22, Division 6, Chapter 8 the following deficiencies were observed and cited. Refer to the following LIC 809-D pages for list of deficiencies. Civil penalty issued in the amount of $500. Failure to correct deficiencies may result in additional civil penalties.


Exit Interview Conducted. Report was reviewed with Program Direct, and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024
LIC809 (FAS) - (06/04)
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