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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600236
Report Date: 10/13/2022
Date Signed: 10/13/2022 11:56:14 AM

Document Has Been Signed on 10/13/2022 11:56 AM - 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:EASTER SEALS SOUTHERN CALIFORNIA CERRITOSFACILITY NUMBER:
198600236
ADMINISTRATOR:REAL, ANGELICAFACILITY TYPE:
775
ADDRESS:11110 ARTESIA BLVD STE CTELEPHONE:
(562) 860-7270
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 35CENSUS: 45DATE:
10/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Victoria Panuco- Program SupervisorTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit to the facility for the purpose of conducting a required annual inspection, using the Infection Control Evaluation Tool. LPA Maldonado met with Program Coordinator Adrian Perez and explained the purpose for the visit. The facility is an Adult Day Program (ADP) licensed to serve 35 adults ages 18 and over, and approved for two non-ambulatory consumers, with restricted health conditions.

The program consists of 1 large single-story building. A tour of the single-story building was conducted with Adrian which included: reception area, 6 offices, file room, 2 restrooms, kitchen, 2 activity rooms, computer lab, and conference room. Shortly after, Program Supervisor Victoria Panuco arrived to assist with the rest of the tour. During the tour, the following was observed: a total of 2 clients were at the facility during the visit. The staff to consumer ratio is 3:1. The program site is clean, safe, sanitary and in good repair. All passageways are free from obstruction. Disinfectants, cleaning solutions and poisons are locked in a janitorial closet and inaccessible to consumers. There are two fire extinguishers were observed in the kitchen and in the copy room. They both ahd recent inspections and were fully charged. There were multiple smoke alarms observed throughout the facility and a carbon monoxide detector in the kitchen. The restrooms were observed to be clean and have the required grab bars. The water temperature was tested, and measured at 113.2*F in bathroom#1 and 96.9*F in bathroom#2. The program maintains a comfortable temperature in each room/office. The First Aid kit is kept in the kitchen and is fully stocked with all required items including a current First Aid manual. Facility does not store or administer medications. Food is not prepared at this program and clients are able to bring their own food. The kitchen area has a refrigerator where the clients can store their food, and is in good repair. Sharps are kept locked and inaccessible in a hallway closet. There are lockers for consumers with extra clothing available for their use- all separated and labeled for each consumer. The last fire/emergency disaster drill was conducted on 08/30/22.

(Report Continued on LIC809-C...)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2022
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA CERRITOS
FACILITY NUMBER: 198600236
VISIT DATE: 10/13/2022
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LPA reviewed 4 consumer files to confirm emergency contact is updated and consumers have health screenings on file. LPA reviewed 2 staff records to confirm health screenings, training and fingerprint clearances.

Facility was observed to have 30 days supplies of Personal Protective Equipment (PPE), and some available at the entrance, readily available for consumers, staff, and visitors. Facility is following COVID-19 recommendations regarding screening all individuals at entry. COVID-19 signage was observed throughout the facility and hand-washing signs were observed in the bathrooms. Sufficient hand soap, hand sanitizer, and paper towels were observe for hand washing.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies were observed during today's visit and will be cited on the LIC809-D.



An exit interview was conducted with Program Supervisor Victoria Panuco and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/13/2022 11:56 AM - It Cannot Be Edited


Created By: Valeria Maldonado On 10/13/2022 at 11:24 AM
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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA CERRITOS
FACILITY NUMBER: 198600236

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/20/2022
Section Cited

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82088 Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care shall deliver hot water. (1)Hot water temperature controls shall... attain a hot water temperature of not less than 105 degrees F... and not more than 120 degrees F...

This requirement was not met as evidenced by:
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Based on observations and interview, the water temperature in bathroom#2 was tested and measured at 96.9*F, which is not within the required limits, which poses a potential Health, Safety, or Personal Rights risk to persons in care.
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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:Fernando Fierros
LICENSING EVALUATOR NAME:Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022


LIC809 (FAS) - (06/04)
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