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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601253
Report Date: 06/06/2022
Date Signed: 06/06/2022 03:50:35 PM

Document Has Been Signed on 06/06/2022 03:50 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:
06/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Arthur Rosel, StaffTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection with the focus of the Infection Control Practices domain. LPA met with Staff, Arthur Rosel, who assisted with the inspection. The purpose of the visit was explained. The facility is licensed for four (4) non-ambulatory clients, 18 to 59 years of age. There are currently 4 clients residing at the home.


LPA toured the facility inside and out and observed the following:
* The facility consists of 4 Client bedrooms, 1 staff office, 3 bathrooms, living room, dining room, kitchen, and an attached garage. The facility is well maintained with no obstructions to the hallways. There are no pools or bodies of water on site.
* Temperature is taken by staff upon entering facility. LPA observed signage throughout the facility and in the restrooms for hand washing hygiene. The facility has sufficient PPE supplies. There are food supplies of 2 day perishable and a week of non-perishable in stock. Knives, cleaning solutions, and disinfectants are locked making them inaccessible to clients. The fire extinguishers were last inspected on 4/30/22. Each of the client's rooms has the proper furniture for a comfortable living environment. The medications are centrally stored and locked in a cart. LPA reviewed medications for all 4 clients and Staff are administering the medications as prescribed. The hot water temperature was measured between the required range of 105-120 degrees Fahrenheit. The smoke detectors and carbon monoxide detector were tested and operable.
No staff or client files were reviewed for this inspection.

There is no deficiency observed during the visit today.

An exit interview was conducted and a copy of this report along with appeal rights were provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2022
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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