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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601471
Report Date: 05/07/2024
Date Signed: 05/07/2024 08:29:48 PM

Document Has Been Signed on 05/07/2024 08:29 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/
DIRECTOR:		SAMUEL CABARONFACILITY TYPE:
735
ADDRESS:3321 WINTERHAVEN DRTELEPHONE:
(909) 596-6686
CITY:LA VERNESTATE: CAZIP CODE:
91750
CAPACITY: 4CENSUS: 3DATE:
05/07/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:53 PM
MET WITH:Administrator Samuel Cabaron TIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Case Management visit on 05/07/2024 at 1:50 pm, in regards to Death Report dated 05/06/2024. LPA Ramirez was met by Direct Support Staff (DSP) Juliet Collins and explained the purpose of the visit. Administrator Samuel Cabaron arrived shortly after to assist with visit. LPA Ramirez inspected facility, including inspection of kitchen area and food supply, and did not observe and health and safety hazards. LPA Ramirez requested and obtained copies of the following documents:
Resident#1 (R1) Face Sheet, Emergency contact information, Individual Personal Plan (IPP), Medication Administration Record (MAR) dated 05/2024, facility meal schedule for 05/06/2024, and copies of contact information of Staff#1, #2 and #3.

No deficiencies are being cited today. LPA Ramirez may return to gather additional information.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2024
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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