198601253-5-14-2026-28-AS-EMAT-DU3R9L-20260514124944

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601253
Report Date: 05/14/2026
Date Signed: 05/14/2026 12:50:07 PM

Document Has Been Signed on 05/14/2026 12:50 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	EASTER SEALS SOUTHERN CALIFORNIA HAYFORD HOME		FACILITY NUMBER:	198601253
ADMINISTRATOR/ DIRECTOR:	NJOROGE, PRISCILLAH		FACILITY TYPE:	735
ADDRESS:	11502 HAYFORD ST		TELEPHONE:	(562) 484-9153
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY: 4		CENSUS: 3	DATE:	05/14/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Administrator- Armando Flores		TIME VISIT/ INSPECTION COMPLETED:	01:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Elena Mallett conducted an unannounced visit for an Annual Inspection. LPA was met by staff in charge Cassandra McCoy. LPA explained the purpose for today's visit. Administrator Armando Flores was contacted by phone and joined the visit shortly after. The facility is licensed to serve 4 Non-Ambulatory Adults ages 18 to 59 years old. The facility currently has 3. clients that are serviced through Harbor Regional Center.

This is a single- story facility located in a residential area in Norwalk, Ca. A tour of the facility includes: 4 client bedrooms, 3 bathrooms, staff office, living room, dining area, pantry, attached garage with laundry, front yard and back yard.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility.
Physical Plant & Environment Safety: LPA toured facility, clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available and all required furnishings were present.All hallways and walkways were free of debris and obstruction. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. Extra linens and towels and hygiene products are readily available for clients. The hot water temperature was tested in the client bathrooms and measured within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked closet and are inaccessible to clients. Smoke detectors and carbon monoxide detectors were tested and were operable. Two fire extinguisher were

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA HAYFORD HOME	FACILITY NUMBER: 198601253
	VISIT DATE: 05/14/2026

NARRATIVE

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observed to be fully charged. All 3 bathrooms were equipped to meet the needs of clients in care. The hot water temperature in two of the bathroom sinks did not measure within Title 22 Regulations of 105F-120F. A deficiency was cited. See 809-D
Operational Requirements: Staff have proper training to meet the needs of the clients in care. Facility has a shaded activity area furnished for outdoor use. Last disaster drill was conducted on 05/13/26.
Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the clients in the case of an emergency.
Personnel Records-Training: Staff files are maintained in a secure location. LPA reviewed 5 staff files during today’s visit, files reviewed contained the following: Criminal Background Clearance, First-Aid/CPR/AED and sufficient on-going training. Administrator Armando Flores certificate expires on 4/18/2028. No issues were observed.
Client Rights-Information: Facility provides telephone landline and internet for the clients. Client rights posters and reporting posters are displayed within the facility.
Client Records-Incident Reports: Client files centrally stored and inaccessible. The files were reviewed for the following documents - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. LPA reviewed all 3 client files with no issues.
Food Service: The kitchen was observed for the ability to prepare and serve food.All appliances were operable. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Food was kept separate from toxins and poisons.
Health Related Service: Staff designated to administer medication have the proper annual training on file. Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers. Incidental Medical & Dental: All training is documented in the facility personnel files.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Facility maintains documentation of the required emergency drills. A full First Aid kit and First Aid Manual was present. Emergency flashlights, food and water were observed. Last disaster drill was conducted on 05/13/26. Facility conducts monthly disaster drills.

Facility handles P&I money for all 3 clients in care. P & I files were reviewed and no issues were observed. Facility maintains a current Surety Bond in the requisite amount.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA HAYFORD HOME	FACILITY NUMBER: 198601253
	VISIT DATE: 05/14/2026

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	A deficiency was cited today Per Title 22 Regulations. An exit interview was conducted with Administrator Armando Flores and copy of this Licensing report was provided along with a copy of Appeal Rights.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/14/2026 12:50 PM - It Cannot Be Edited

Created By: Elena Mallett On 05/14/2026 at 12:15 PM

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 HAYFORD HOME	FACILITY NUMBER: 198601253
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80088(e)(1)

80088 Furniture, Fixtures, Equipment and Supplies (e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that hot water temperture in Bathroom 1 and Bathroom 3 did not measure within Title 22 Regulations of 105- 120 F. Bathroom 1( 96 F) and Bathroom 2 (102 F)which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/21/2026
	Plan of Correction
1 2 3 4	Administrator will keep a water log for 3 consecutive days measuring the hot water temperture at 3 different times of day from the faucets in Bathroom 1 and Bathroom 3 and send this log to LPA via office fax by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:

	Elena Mallett
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026

LIC809 (FAS) - (06/04)

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