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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601471
Report Date: 11/27/2023
Date Signed: 11/27/2023 07:09:41 PM

Document Has Been Signed on 11/27/2023 07:09 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 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:
11/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:14 PM
MET WITH:Administrator Loveday ChinakaTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 11/27/2023. LPA Ramirez was met by Administrator Loveday Chinaka and explained the purpose of the visit. The facility is licensed serve four (4) developmentally disabled clients 18-59 years old, of which two (2) may be non-ambulatory. LPA Ramirez requested and obtained copies of Personnel Report (LIC 500), and Client Roster (LIC 9020). All clients in the facility receive services from San Gabriel/Pomona Regional Center.

LPA OBSERVATIONS: Tour began at 1:07 pm. The facility is a single-story dwelling located in a residential area with four (4) client bedrooms, one (1) staff office, two (2) bathrooms, kitchen, dining room, living room, attached garage, front yard, and backyard.

Front Yard: LPA Ramirez observed front yard to be free of hazards. Front yard was well maintained.

Kitchen: LPA Ramirez observed appliances to be in working order. LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed a fully charger fire extinguisher nearby. Kitchen sink temperature was measured at 109.8 degree F.

Dining Room/Living room: Dining room was observed to contain one table with four (4) chairs. Living room was observed to contain plenty of lighting. LPA Ramirez observed a fully charged fire extinguisher nearby. LPA Ramirez observed signage promoting cough and handwashing etiquette in this area. LPA Ramirez observed nearby thermostat to read 74 degrees F. LPA Ramirez observed two (2) out of the four (4) clients sitting in living room area.

Linen Closet/Supply Closet: Observed to contain plenty linens, towels, and hygiene products.

Client Rooms 1 - 4: LPA Ramirez observed all client bedrooms to contain the required linens, furnishings, and lighting. All client bedrooms are private.

See 809-C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/27/2023
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA WINTERHAVEN HOME
FACILITY NUMBER: 198601471
VISIT DATE: 11/27/2023
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Bathroom 1-2: LPA Ramirez observed grab bars in all showers and non slip mats in all bathrooms showers. LPA Ramirez observed signage promoting proper handwashing etiquette near sink. Water temperature in bathroom#1 was 107.4 degree F and bathroom#2 water temperature was 110.8 degree F.

Centrally Stored Medications: LPA Ramirez observed centrally stored medication in staff office which was inaccessible to two (2) out of the four (4) clients in care.

Backyard: No large bodies of water were observed and area was free of hazards.

Emergency Drills: Proof of last documented emergency drills were conducted on 10/01/23 at 9:15 am, 9/14/23 at 12pm and 08/02/23 at 8:15 pm.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide and smoke detectors in hallways. Smoke detectors were observed to be operable during visit.

Staff Personnel Files: Staff files are maintained at the facility. LPA Ramirez reviewed three (3) staff files. LPA Ramirez observed current Administrators Certificate with an expiration date of 04/01/2024.

Client Files: Client files are maintained at the facility. LPA Ramirez reviewed four (4) client files. LPA Ramirez observed two (2) age exceptions for two (2) out of the four (4) clients in care.

Infection Control Plan: LPA Ramirez reviewed current infection control plan.

Exit interview was conducted. No deficiencies were cited. A copy of this report was provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
LIC809 (FAS) - (06/04)
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