198601273-9-10-2024-28-AS-TRES-D8YRBX-20240910125327

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601273
Report Date: 09/10/2024
Date Signed: 09/10/2024 12:53:32 PM

Document Has Been Signed on 09/10/2024 12:53 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 FACULTY HOME		FACILITY NUMBER:	198601273
ADMINISTRATOR/ DIRECTOR:	NJOROGE, PRISCILLAH		FACILITY TYPE:	735
ADDRESS:	11644 FACULTY DR		TELEPHONE:	(562) 402-0252
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY: 3		CENSUS: 3	DATE:	09/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:52 AM
MET WITH:	Administrator Armando Flores		TIME VISIT/ INSPECTION COMPLETED:	12:57 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 Analyst (LPA) Tyler Reyes conducted an unannounced visit at the facility for the purpose of conducting the required annual inspection. LPA utilized the Compliance and Regulatory Enforcement (CARE) Tool to evaluate the facility. LPA met with Administrator Armando Flores and explained the purpose for the visit. The facility is licensed to serve 3 developmentally disabled clients ages 18-59 years old and approved for (3) non-ambulatory and/ or ambulatory clients. Facility is operating within the approved capacity. Currently, there are three (3) clients in placement. All clients residing at this facility receive case management services provided by Harbor Regional Center. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical Services, Disaster Preparedness, and Emergency Intervention. During the visit LPA observed the following: Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has sufficient PPE supplies, has an Infection Control Plan and Mitigation Plan. Facility has COVID-19 signage posted throughout the facility. Bathrooms have hand washing signs, soap and paper towels. Per Facility Administrator two (2) clients have COVID-19 vaccines including boosters. Per Facility Administrator all staff also have the COVID-19 vaccines including boosters. Facility Administrator is adhering to infection control requirements. Refer to LIC 809C for continuation of report

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Tyler Reyes
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

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

FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA FACULTY HOME	FACILITY NUMBER: 198601273
	VISIT DATE: 09/10/2024

NARRATIVE

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Operational Requirements: The last Emergency Disaster Drill was conducted on 6/17/24.

Physical Plant & Environment Safety: The home is located in a residential area, the single-story facility consisting of: kitchen, three private client bedrooms, two client bathrooms, garage area, laundry area, pantry, office, medication area and backyard. Facility also has an attached garage that is used for storage. All client rooms were checked. All clients beds have the required linens which were in good condition at the time of the visit. All bedrooms had sufficient closet/ storage space. Bathrooms are clean and operational and were observed to be within Title 22 regulations. Facility toilets and water faucets worked properly. Shower was free of mold/mildew, adequate lighting, and sufficient toiletries are accessible to clients. Water temperature for restroom #1 measured at 116 degrees F and restroom #2 measured at 117.3 degrees F. Facility temperature was comfortable throughout the facility. LPA observed the facility to be clean and in good repair. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to clients. Hazardous toxins and/or items are inaccessible to clients, fire extinguisher(s) are fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. A shaded area with chairs is provided for clients in the patio area in the backyard of the facility

Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator. Staff have current CPR/first aid training and sufficient on-going training that meets the annual requirement. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting.

Refer to LIC 809C for continuation of report

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Tyler Reyes
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

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 FACULTY HOME	FACILITY NUMBER: 198601273
	VISIT DATE: 09/10/2024

NARRATIVE

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Client Rights-Information: Client personal rights and House Rules are posted.

Client Records-Incident Reports: Client files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report (including T.B and Ambulatory Status), and Appraisal Needs and Services Plan.

Food Service: The facility has sufficient food supplies of 2-day perishable and 7 day supply of non-perishable items. The food is properly stored in the refrigerator which is clean and well-maintained. Kitchen is kept clean and free from rodents and other bugs/ insects. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: The medications are centrally stored and in their original containers. LPA reviewed medication for (3) clients. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubble packed and delivered monthly.

Incidental Medical Services: Per Facility Administrator, there are two (2) clients at this home with incidental medical services and a care plan is on file for both.

Disaster Preparedness: The facility has an Emergency Disaster Plan readily accessible.

No deficiencies noted. Exit interview and a copy of this report was provided to Administrator Armando Flores.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Tyler Reyes
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

LIC809 (FAS) - (06/04)

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