197610084-10-2-2024-31-AS-JGTN-D9NSV6-20241002141214

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610084
Report Date: 10/02/2024
Date Signed: 10/02/2024 02:12:21 PM

Document Has Been Signed on 10/02/2024 02:12 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	EASTERSEALS SOUTHERN CALIFORNIA INC		FACILITY NUMBER:	197610084
ADMINISTRATOR/ DIRECTOR:	FERNANDEZ, CYNTHIA		FACILITY TYPE:	775
ADDRESS:	44480 20TH STREET W		TELEPHONE:	(818) 388-7428
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93534
CAPACITY: 100		CENSUS: 47	DATE:	10/02/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:10 AM
MET WITH:	Carlos Guillen - Program Director		TIME VISIT/ INSPECTION COMPLETED:	02:15 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 Analysts (LPAs) Gary Tan and Angelica Segovia conducted an unannounced Annual/Required visit to this facility. LPAs met with the Program Director Carlos Guillen and explained the reason of the visit.

LPAs conducted a tour of the facility with Mr. Guillen at around 10:35 AM inside and outside to ensure that there is no health and safety hazards and that facility is in compliance with Title 22 Regulations. The facility is a single storey building fire cleared for one hundred (100) ambulatory residents, twenty five (25) of which may be non-ambulatory. There are nine (9) activity rooms, total of eight (8) bathrooms, five (5) staff offices, a janitor's closet, four (4) storage rooms, a kitchen/dining area, a kitchenette, two (2) conference rooms and a wellness room.

The first front door is the entrance being utilized for the visitors and another entrance door for the staff and participants. There is a sign on the front door that everyone entering at the facility that wearing mask is optional. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation and Infection Plan. Signs to wear a mask and other Covid 19 prevention protocol signs were posted inside. All trash cans were observed to be with cover. The facility has a designated waiting area upon entrance. The facility has sufficient stock of PPE in the storage.

Common areas were observed for the safety and the ability to serve the needs of clients, including cleanliness and orderliness. LPAs checked physical plant, client records, and staff records. LPAs observed the storage areas for toxins, sharps, and other hazardous items to be locked and secured.

Dining/Kitchen Area - During the tour of this area, LPA observed several tables and chairs for clients' use. Clients bring their own food and only snacks are served upon request. (continued on LIC 809-C)

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: EASTERSEALS SOUTHERN CALIFORNIA INC	FACILITY NUMBER: 197610084
	VISIT DATE: 10/02/2024

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

(continued from LIC 809)

Fire extinguishers were checked and were found fully charged and last serviced on 09/20/24. Fire and earthquake drill was last done on 08/01/24. The facility has smoke alarms that are hardwired and interconnected. There is a carbon monoxide detector installed in the facility. There is no body of water in the facility.

Restrooms - LPAs observed several restrooms at the facility were clean and sanitary. The restrooms have grab bars and some restrooms are equipped with changing tables. Hot water temperature was measured at a range of 111.1°F to 111.3°F in common bathroom areas.

Records Review - Four (4) residents records were reviewed and appeared to be complete and updated. Five (5) staff records were reviewed and all staff records appear to be complete and updated.

There is complete first aid kit located in the kitchen and another in the reception area. Emergency food were observed to be sufficient stored in the storage room near the kitchen.

There is no health and safety issues during this visit.

Exit Interview Conducted. Appeal Rights and a copy of this report has been issued.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2