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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601471
Report Date: 03/13/2025
Date Signed: 03/20/2025 02:46:40 PM

Document Has Been Signed on 03/20/2025 02:46 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:
03/13/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:17 PM
MET WITH:Administrator Samuel CabronTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted a Case Management Visit-Incident on 03/13/2025, stemming from Special Incident Report received on 12/19/2024. LPA was greeted by Administrator Samuel Cabaron and explained the purpose of the visit.

Case management- incident:

According to incident report dated 12/19/2024, staff#1 (S1), reported to Administrator Cabaron on 12/17/24 at 7pm, that client#1 (C1) was not administered three of their 4pm medications. C1’s primary care physician (PCP) was notified and advised staff to closely monitor C1 till the following morning for any possible side effects. Staff later reported C1 did not have any adverse reactions. Facility registered nurse (RN) would provide re-training to staff before resuming medications passing.

On 3/13/2025, LPA Ramirez toured facility and reviewed training records for staff. LPA Ramirez observed medications re-training for staff was conducted on 12/20/2024 .

Based on records reviewed and interviews conducted, one (1) type A deficiency is being cited for violation of Title 22, Division 6, Chapter 1, Article 06. Continuing Requirements- 80065 Personnel Requirements- (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.

Exit interview was conducted and a copy of this report, 809-D and appeals rights was provided via email.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2025
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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Document Has Been Signed on 03/20/2025 02:46 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 03/13/2025 at 02:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA WINTERHAVEN HOME
FACILITY NUMBER: 198601471

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/14/2025
Section Cited
CCR
80065(a)

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(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.
This requirement was not met as evidenced by:
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Licensee conducted staff re-training on 12/20/24. This clears 24hr POC. No further action is required.
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Staff did not administer 3 of C1's 4pm scheduled medications.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2025


LIC809 (FAS) - (06/04)
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