<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610084
Report Date: 05/22/2024
Date Signed: 05/22/2024 02:37:46 PM

Document Has Been Signed on 05/22/2024 02:37 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/
DIRECTOR:		FERNANDEZ, CYNTHIAFACILITY TYPE:
775
ADDRESS:44480 20TH STREET WTELEPHONE:
(818) 388-7428
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 100CENSUS: 45DATE:
05/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Carlos GuillenTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Abeye Duguma conducted unannounced case management visit to the facility. At around 11:15am LPA met with the Program Director, Carlos Guillen, explained the purpose of this visit, conducted a physical plant tour and requested documents.

On 05/15/2024, an incident was reported to the department stating that on 05/14/2024 Client #1 (C1) was struck in the back of the head-neck area by Staff #1 (S1).

LPA interviewed staff from around 11:45 PM to 12:45 PM. During interviews, Staff #2 (S2) stated that on 05/14/2024 at around 2:15pm, when C1 was preparing to leave the facility and board a bus, C1 was noticeably unwell. S2 asked if C1 was ok and sat them down. C1 began shaking but did not lose consciousness. C1 requested that their responsible party (RP) be called to be taken home. S2 asked what happened and C1 stated S1 hit them and gestured towards the back of the head-neck area. After explaining, S2 checked C1 for marks but did not observe any. C1 started to shake again then S2 called paramedics and the RP. Paramedics checked all vitals and stated C1 was ok but that it was ultimately RP’s choice to take C1 to the hospital. RP decided to have paramedics take C1 to the hospital. S2 contacted the RP later that evening and RP explained that the incident was deemed a anxiety attack by medical professionals. S2 interviewed S1 regarding the incident and they stated that all they did was tap C1 on the shoulder to say hello and C1 stated that they were startled. Staff #3 (S3) was with S1 during the time of the alleged incident and did not witness any physical or verbal altercation between C1 and S1. Staff #4 (S4) stated that C1 had headphones on and was dancing prior to and after the alleged incident. S1 does not have any history of physical or verbal altercations in the 24 years that they have worked in the facility.

(CONT. on LIC 809-C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2024
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 2
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: 05/22/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA interviewed five (05) clients between 12:45 PM to 1:45 PM. During interviews C1 stated S1 hit them in the head neck area. C1 added that it did not hurt, no one witnessed the incident and that they did not have an altercation prior to the alleged physical contact. C1 stated they feel safe in the facility and does not believe that S1 is a danger to them or others. C1 does not have a history of physical altercations or making false statements. C1 also does not have a history of anxiety attacks. All other clients stated staff have never physically or verbally abused them and that they treat them all with dignity and respect. All other clients also stated they have never witnessed others being physically or verbally abused.

S1 is currently on administrative leave but is due to return to work after Regional Center’s investigation. The incident was deemed unsubstantiated by the Regional Center.

No further action at this time.

No health and safety hazards were noted during the visit.

Exit interview was conducted and a copy of report was issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2