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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610084
Report Date: 09/27/2021
Date Signed: 09/27/2021 04:02:57 PM

Document Has Been Signed on 09/27/2021 04:02 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:EASTERSEALS SOUTHERN CALIFORNIA INCFACILITY NUMBER:
197610084
ADMINISTRATOR:FERNANDEZ, CYNTHIAFACILITY TYPE:
775
ADDRESS:44480 20TH STREET WTELEPHONE:
(818) 388-7428
CITY:LANCASERSTATE: CAZIP CODE:
93534
CAPACITY: 100CENSUS: 0DATE:
09/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Cynthia FernandezTIME COMPLETED:
03:35 PM
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LPA Spaeth conducted an unannounced annual visit to the facility and arrived at 2:00 pm. LPA was greeted by Brian Nguyer (S1) and LPA observed S1 was wearing a mask. Upon entering the location, LPA observed the sign in station which contained thermometer, hand sanitizer, masks, and sign in sheet. LPA's temperature was recorded. LPA was then directed to the conference room and was greeted by Administrator Cynthia Fernandez. LPA stated the purpose of the visit is to conduct the annual visit. LPA also met the new staff member, Danshelle Day who will be the Administrator upon completion of training. Administrator Fernandez and LPA discussed the documentation needed for this change.

Administrator explained that staff are still meeting with clients via Zoom due the COVID variance but the program will begin in the near future with a designated number of participants. Administrator explained the start date has not been determined at this time. However, Administrator will inform LPA once the date has been determined. Administrator stated the staff to client ratio for this program is one to three. However, when clients return to the program, the ratio will be either one to one or one to two. Administrator explained eight participants who feel comfortable wearing a mask will be attending the program twice per week (Monday through Friday). Zoom meetings will take place every Friday.

Administrator and LPA began the tour at 2:05 pm at the front entrance and stated all clients and staff will enter from the front door. COVID signs are posted at the front door. LPA observed upon entrance, all guests enter a reception area and there is a key pad wdoor where a staff member will open the key pad door to screen all clients and staff members. LPA then observed eight open rooms where staff members will work one on one with clients during the three hour sessions. LPA Spaeth observed there are three sets of bathroom locations. Each location has designated male and female bathrooms. Each
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2021
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: EASTERSEALS SOUTHERN CALIFORNIA INC
FACILITY NUMBER: 197610084
VISIT DATE: 09/27/2021
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bathroom contained wash your hands sign, hand soap, and paper towels. Each bathroom was neat and clean. LPA observed the kitchen/dining room combination. LPA observed the dining room was empty but Administrator stated clients will eat snacks at the one on one stations. There are two microwave appliances within the kitchen area and the appliances were six feet apart. LPA observed wash your hands sign, hand soap and paper towels within the kitchen area. LPA observed the isolation room on the east side of the building. The room is large and contained PPE such as hospital gowns.

LPA was then escorted to a storage area which contained a 90 day supply of PPE including surgical masks, hand sanitizer, hand soap, gloves and other needed supplies. LPA was then escorted to the staff offices and LPA observed staff members were social distanced throughout this section of the building and were wearing masks. LPA observed the exit location for the program. The space is a large space where social distancing can be observed when clients exit the building.

There are no deficiencies to report at this time. Exit interview conducted, and LPA confirmed a copy of the signed report will be emailed to Administrator.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021
LIC809 (FAS) - (06/04)
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