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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601467
Report Date: 11/14/2022
Date Signed: 11/14/2022 12:48:53 PM

Document Has Been Signed on 11/14/2022 12:48 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:EASTER SEALS SOUTHERN CALIFORNIA KIRKWOOD HOMEFACILITY NUMBER:
198601467
ADMINISTRATOR:SOPHESIAS JOHNSONFACILITY TYPE:
735
ADDRESS:564 KIRKWOOD AVETELEPHONE:
(818) 331-7138
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 4CENSUS: 3DATE:
11/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Jorge Romero/Facility AdministratorTIME COMPLETED:
01:05 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Jorge Romero and explained the purpose of today's visit.

This home consists of the following: (4) private client bedrooms (each client has their own private bedroom), (2) full bathrooms, living room, kitchen, dinning area, laundry room and has an attached garage.

The following were observed/inspected: .
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility and throughout the facility. Signs are posted to promote hand washing, cough/sneeze etiquette, and physical distancing were also observed.
  • PPE supplies observed (stored inside the garage).
  • Incontinence care supplies observed (stored inside the garage).
  • Hygiene supplies observed (stored inside the garage).
  • Restrooms have hand soap, hand sanitizer and hand paper towels. Hand washing signs posted.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed.
  • Per Administrator, all (3) clients are fully vaccinated including (2) boosters and have the flu vaccine.
  • Per Administrator, all staff are fully vaccinated and have boosters.
  • Medication reviewed for (3) Clients (Client #1 through Client #3).
  • Staff responsible for direct care and supervision will wear masks.
  • Clients were be socially distanced according to local public health guidelines.

Exit interview conducted, a copy of this report and Appeal Rights were provided to Jorge Romero
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2022
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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