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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601471
Report Date: 11/24/2024
Date Signed: 11/24/2024 04:24:35 PM

Document Has Been Signed on 11/24/2024 04:24 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: 2DATE:
11/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:32 AM
MET WITH:Administrator Samuel CabaronTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 11/24/2024. LPA Ramirez was met by Administrator Samuel Benedict Cabaron 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. All clients in the facility receive services from San Gabriel/Pomona Regional Center.

LPA OBSERVATIONS: The facility is a single-story dwelling located in a residential area with four (4) client bedrooms, 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.

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 hand washing etiquette in this area. LPA Ramirez observed nearby thermostat to read 72 degrees F.

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. Two (2) out of the four (4) client bedrooms are unoccupied.

SEE 809-C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 11/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 11/24/2024
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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 bathroom#2 to be wheelchair accessible.

Centrally Stored Medications: LPA Ramirez observed centrally stored medications to be inaccessible to clients in care.

Backyard: Well maintained with plenty of shade and free of hazards.

Emergency Drills: Proof of last documented emergency drills were conducted on 11/5/2024 & 10/05/2024.

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 two (2) staff files. LPA Ramirez observed a pending renewal for Administrators Certificate for Samuel Benedict Cabaron. Back up Administrator Loveday Chinaka, administrator's certificate expires 4/01/2026.

Client Files: Two (2) client files were reviewed. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights, and Individual Program Plan were observed.

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

Exit interview was conducted. No violations were observed. A copy of this report was provided via email.

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

DATE: 11/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2024
LIC809 (FAS) - (06/04)
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