198601321-3-19-2024-11-AS-SDAY-D3HUK8-20240319153844

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601321
Report Date: 03/19/2024
Date Signed: 03/19/2024 03:38:51 PM

Document Has Been Signed on 03/19/2024 03:38 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	EASTER SEALS SOUTHERN CALIFORNIA WEST 88TH ST HOME		FACILITY NUMBER:	198601321
ADMINISTRATOR:	VELASQUEZ, VILMA		FACILITY TYPE:	735
ADDRESS:	6701 W 88TH ST		TELEPHONE:	(310) 649-5364
CITY:	WESTCHESTER	STATE: CA	ZIP CODE:	90045
CAPACITY: 4		CENSUS: 3	DATE:	03/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Esmeralda Maya		TIME COMPLETED:	03:50 PM

NARRATIVE

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On 3/19/24, Licensing Program Analyst (LPA) Sparkle Day conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with DSP, Esmeralda Maya and was later joined by Administrator Edgar Arana and the purpose of today’s visit was explained. The facility is licensed to operate for (4) developmentally disabled adults ages 18 through 59 of which 4 can be non ambulatory. Currently, the home has (3) clients. The clients are Westside Regional Center clients. None of the clients have Restricted Health Care Conditions and none are utilizing postural supports or protective devices.

The facility is a one home located in a residential neighborhood. The property consists of the following: 4 client bedrooms, 2 common bathrooms, living room/ dining area, den, garage which houses the washer and dryer and Administrator office. An outdoor shaded area was observed.

LPA conducted a records review of (3) client records, (3) staff records, (3) clients Personal & Incidental Records and reviewed the facility disaster plan. All client & Staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (3) Client Medication Administration Records and did not observed any discrepancies at the time of visit.

At 1:40 pm LPA and staff Esmeralda Maya toured the inside and outside of the facility. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed , plenty of dresser and closet space was observed. Walls and floors were clean and in good repair. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured between 105-120F ( Bathroom #1 110.3F & Bathroom #2 112.3F).

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Sparkle Day
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA WEST 88TH ST HOME	FACILITY NUMBER: 198601321
	VISIT DATE: 03/19/2024

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Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide detector was observed and operational. Smoke detectors were working properly, fire extinguishers were fully charged, toxins and knifes were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Outside grounds were toured and no bodies of water were observed. Exits/ Walkways around the home were free of debris and hazards.

LPA Day observed that the cabinet in the dining room has a broken glass.

Exit interview conducted with Edgar Arana Administrator and a copy of the report was left at time of visit.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Sparkle Day
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/19/2024 03:38 PM - It Cannot Be Edited

Created By: Sparkle Day On 03/19/2024 at 03:05 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA WEST 88TH ST HOME	FACILITY NUMBER: 198601321
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. The dining cabinet in the diningroom has a broken glass.
	POC Due Date: 03/26/2024
	Plan of Correction
1 2 3 4	Licensee will repair and/or remove the cabinet and send picture of repair to Sparkle.day@dss.ca.gov by POC 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.

SUPERVISOR'S NAME:

Janae Hammond

LICENSING EVALUATOR NAME:

Sparkle Day

LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

LIC809 (FAS) - (06/04)

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