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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601253
Report Date: 10/26/2021
Date Signed: 11/10/2021 02:10:06 PM

Document Has Been Signed on 11/10/2021 02:10 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:EASTER SEALS SOUTHERN CALIFORNIA HAYFORD HOMEFACILITY NUMBER:
198601253
ADMINISTRATOR:NJOROGE, PRISCILLAHFACILITY TYPE:
735
ADDRESS:11502 HAYFORD STTELEPHONE:
(562) 484-9153
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 4CENSUS: 4DATE:
10/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jacqueline Jenkins/Socrates YambaoTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Nicol Wesley conducted an unannounced Required 1 year inspection at the facility and met with staff Jacqueline Jenkins and Socrates Yamboa and spoke to Administrator Maria Drummond on the phone to explain the purpose for todays visit. Prior to the visit LPA Wesley conducted a risk assessment for on-site inspection. The facility phone number is 562 484 9153. The facility consist of four resident bedrooms, office, three bathrooms(1 located in bedroom #1), living room, kitchen with dining area, and shaded area with tables and chairs located in the back yard, and an attached garage(washer/dryer, storage).

During the visit the Infection control domain was used and the following areas were observed/inspected: The facility had all postings at the front entrance, bathrooms, and throughout the facility. Hand sanitizing gel and masks were located at the entry of each room. A Pre screening area with PPE supplies was observed upon entry into the facility. The Mitigation plan was reviewed and approved on 03/19/21.

LPA Wesley conducted a complete tour of the facility, and observe the supply of food. Resident medications, and medication logs were reviewed. The smoke detectors/carbon monoxide detector are operable. LPA observed 3 fire extinguishers(kitchen, hallway, office). The water temperature was tested and measured 120 degrees F.

Administrators certificate for Maria M. Drummond #6017412735, expires on 10/23/2022 .

There were no deficiencies cited.

Exit interview conducted.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Nicol Wesley
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2021
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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