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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601471
Report Date: 07/18/2024
Date Signed: 07/18/2024 10:27:23 AM

Document Has Been Signed on 07/18/2024 10:27 AM - 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: 2DATE:
07/18/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:02 AM
MET WITH:Administrator Samuel CabaronTIME VISIT/
INSPECTION COMPLETED:
10:14 AM
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On 7/18/2024, Licensing Program Analyst (LPA) Kimberly Ramirez conducted a subsequent unannounced Case Management visit regarding the unexpected death of client#1 (C1) at the facility on 05/06/2024. LPA Ramirez was greeted by Administrator Samuel Cabaron and explained the purpose of the visit. LPA Ramirez requested and obtained a copy of C1 Death Certificate. Cause of death according to C1's death certificate does not indicate a homicide or suspicious death. At this time no further follow is required in regards to C1's unexpected death at the facility. No deficiencies were observed during this visit. Exit interview was conducted. A copy of this report was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2024
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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