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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610084
Report Date: 11/06/2023
Date Signed: 11/06/2023 02:45:13 PM

Document Has Been Signed on 11/06/2023 02:45 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:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 100CENSUS: 65DATE:
11/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Carlos GuillenTIME COMPLETED:
02:50 PM
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On 11/06/23, Licensing Program Analyst (LPA) Tihesha Smith conducted an announced Case Management Incident visit to follow up with the facility about the Special Incident Report (SIR) received by CCL on 11/03/2023 that a consumer (Client #1, C1) was touch on the vaginal area on top of clothing by a participant (Client #2, C2).

LPA met with Program Director (PD) Carlos Guillen, who was informed the reason of the visit, and who reported the incident to CCL the same day.

Interview with Director revealed that C1 and Staff #1 (S1) came to him on 11/02/23 to report that C2 had slide their hand across the top of C1’s jeans. PD revealed asked C1, if they were okay and if they wanted to file a police report. Per interview with PD, C1 did not want to file a police report and did not want to interact with C2 and staff complied with request. PD also revealed at approximately 1:20 pm, they and Supervising Program Director (SPD) Lavonna Matthews spoke with C2, who admitted to touching C1 on top of clothing. C2 was reminded of personal rights, personal space of each consumer and a meeting with Family and Regional Center is scheduled for 11/07/23. Interview with S1 revealed that C2 had slide their hand across top of C1s pants near the private area and they reported the incident immediately to the PD on 11/02/23.

LPA interviewed C1, who did not reveal any details regarding the incident but pointed to their jeans when asked if they were touched by C2. C1 stated they are fine and enjoy coming to the program. LPA interviewed C2, who did not reveal any details regarding the incident.

Based on interviews and LPA's observation no neglect by any staff occurred and the PD reported the incident appropriately.

No deficiency will be cited at this time.
Exit interview conducted and copy of this report signed and given
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2023
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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