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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601471
Report Date: 11/24/2021
Date Signed: 11/24/2021 01:12:21 PM

Document Has Been Signed on 11/24/2021 01:12 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:EASTER SEALS SOUTHERN CALIFORNIA WINTERHAVEN HOMEFACILITY NUMBER:
198601471
ADMINISTRATOR:GODINEZ, JUANFACILITY TYPE:
735
ADDRESS:3321 WINTERHAVEN DRTELEPHONE:
(909) 596-6686
CITY:LA VERNESTATE: CAZIP CODE:
91750
CAPACITY: 4CENSUS: 4DATE:
11/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Loveday Chinaka - AdministratorTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with Administrator Loveday Chinaka and explained the reason for the visit. Physical Plant was toured, clients files and medication records were reviewed, staffs files records reviewed and food supply was inspected.

LPA and Administrator toured the home and inspected 4 client bedrooms, 2 bathrooms, kitchen, dining area, living room, staff office, backyard and attached garage. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the clients located in the backyard. Passageways and exits are free of obstruction. The water temperature was tested in bathroom #1 and bathroom #2 and both measured at 109 degrees F which is within the required 105 - 120 degrees. Client bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Client beds have the required linen and the linen is in good condition. There is a cabinet in the hallway with extra clean linen and towels. Smoke detectors with carbon monoxide were observed in each room and throughout the facility. There are 2 fire extinguishers located in the kitchen and garage which are fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in a cabinet in the garage and are inaccessible to clients. Cleaning supplies and toxins are locked in a cabinet in the hallway and are inaccessible to clients. First Aid kit was fully stocked with current manual and it is kept in a cabinet above the refrigerator in the kitchen. Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing. Sufficient supply of 2 days perishable & 7 days non-perishable foods were observed in the kitchen and in the refrigerator. Medications are centrally stored in the staff office and are locked in a cabinet. Client and staff files are kept locked in a cabinet in the staff office. All four of the client files and medications were reviewed and no deficiencies were found. Medications are documented properly and given as prescribed. Two staff files were reviewed and no deficiencies were found.
(CONTINUED TO LIC 809C)
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 11/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/24/2021
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA WINTERHAVEN HOME
FACILITY NUMBER: 198601471
VISIT DATE: 11/24/2021
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Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 11/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2021
LIC809 (FAS) - (06/04)
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