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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601321
Report Date: 03/29/2023
Date Signed: 04/20/2023 11:35:44 AM

Document Has Been Signed on 04/20/2023 11:35 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:EASTER SEALS SOUTHERN CALIFORNIA WEST 88TH ST HOMEFACILITY NUMBER:
198601321
ADMINISTRATOR:VELASQUEZ, VILMAFACILITY TYPE:
735
ADDRESS:6701 W 88TH STTELEPHONE:
(310) 649-5364
CITY:WESTCHESTERSTATE: CAZIP CODE:
90045
CAPACITY: 4CENSUS: 4DATE:
03/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Edgar AranaTIME COMPLETED:
03:30 PM
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On 03/29/23, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Caregivers Maria Reyes and Dianette Osborne. Administrator Edgar Arana and Director Kimya Oliver arrived later and joined the visit. LPA explained the purpose of today’s visit. The facility is licensed to operate for four (4) non-ambulatory developmentally disabled adults ages 18 through 59. The consumers are Westside Regional Center clients.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) clients' rooms, two (2) common bathrooms, a living area, a dining area, a kitchen, and an outside patio area.

LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. Bathrooms were operational. The water temperature measured 114.2 degrees F. A comfortable temperature was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected, and sufficient perishable and non-perishable food supplies were observed. The fire extinguisher was charged, and smoke detectors and carbon monoxide were operable. A review of the Medication Records Administration (MAR) was observed to be maintained in order and accurately. A working telephone was available and operable. An inspection audit of four clients’ (C1-C4) service records and three staff (S1-S3) personnel files were completed.

Evaluation Report continues LIC 9099-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2023
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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA WEST 88TH ST HOME
FACILITY NUMBER: 198601321
VISIT DATE: 03/29/2023
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LPA identified the following deficiencies:

Client #1 – missing admission agreement, current appraisal, immunization record, and safeguard of property/valuables

Client #2 – missing current appraisal, immunization record, and safeguards for property/valuables

Client #3 – missing current appraisal

Client #4 – missing immunization record

Staff #1-#3 – personnel files are not available in the facility for LPA‘s review.

According to the California Code of Regulations (Title 22, Division 6, Chapter 1), the following deficiencies have been observed and a citation issued (ref. LIC 9099D).



An exit interview was conducted with Administrator Edgar Arana and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/20/2023 11:35 AM - It Cannot Be Edited


Created By: Lourdes Montoya On 03/29/2023 at 02:47 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA WEST 88TH ST HOME
FACILITY NUMBER: 198601321

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(e)
All personnel records shall be maintained at the facility site and shall be available to the licensing agency for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. The licensee failed to provide three staff's (S1-S3) personnel records to LPA during the annual inspection. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2023
Plan of Correction
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The administrator will email the personnel records of three staff (S1-S3) to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.
Type B
Section Cited
CCR
80070(a)

The licensee shall ensure that a separate, complete, and current records is maintained in the facility for each client.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. The licensee failed to show the licensing agency complete and current records of all four clients (C1-C4). This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2023
Plan of Correction
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The administrator agreed to submit the missing records of clients #1-#4 to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.
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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2023


LIC809 (FAS) - (06/04)
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