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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601467
Report Date: 02/24/2025
Date Signed: 02/24/2025 01:28:42 PM

Document Has Been Signed on 02/24/2025 01:28 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/
DIRECTOR:		JORGE ROMEROFACILITY TYPE:
735
ADDRESS:564 KIRKWOOD AVETELEPHONE:
(818) 331-7138
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 4CENSUS: 3DATE:
02/24/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Jorge RomeroTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted a Case Management visit today regarding a special incident which occurred on 02/03/25 involving Client #1 (C-1). LPA met with Jorge Romero and explained the purpose of today’s visit.

During this visit, LPA reviewed C-1's file and obtained relevant documentation. LPA also interviewed Mr. Romero (Facility Administrator).

LPA toured the facility grounds and did not observe any health and safety concerns. Mr. Romero will continue to keep LPA informed of any further developments pertaining to C-1's incident.

An exit interview was conducted and a copy of this report was given to Jorge Romero.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2025
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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