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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601530
Report Date: 05/14/2024
Date Signed: 05/14/2024 11:49:59 AM

Document Has Been Signed on 05/14/2024 11:49 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 PROSPERO HOMEFACILITY NUMBER:
198601530
ADMINISTRATOR/
DIRECTOR:
SAMUEL BENEDICT B CABARONFACILITY TYPE:
735
ADDRESS:1046 N PROSPERO DRTELEPHONE:
(626) 339-1482
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY: 4CENSUS: 4DATE:
05/14/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:01 AM
MET WITH:Loveday Chinaka, DirectorTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to continue with the annual inspection. LPA met with administrator, Samuel Cabaron, who assisted with the visit. The initial visit began on 5/10/24.

During the visit today, LPA completed the remainder of the inspection and the following were reviewed:
Staffing: The facility has sufficient staffing to meet the needs of the residents. There is an awake staff for the overnight shift. All staff members have current CPR & First Aid certificates.
Personnel Records-Training: LPA reviewed 4 Staff files. The administrator's (Samual Cabaron) certificate expires on 6/25/24. Staff have fingerprint clearance and associated to the facility. Staff files have the required documents such as personnel record, health screening with TB results, employee rights form, and in-service training.
Client Rights - Information: There are no clients utilizing any postural supports. Clients have internet access.
Client Records - Incident Reports: LPA reviewed all 4 client files. Each of the files has the required documents such as the admission agreement, medical assessment including TB results, current IPP reports from the regional center, and safeguarding of property and cash resources forms.
Health-Related Services: Medications are centrally locked and inaccessible to clients. LPA reviewed medications for 4 clients. There were no discrepancies found and PRN meds are documented when given.
Incidental Medical Services: There are no clients with any restricted or prohibited health conditions residing at the facility.
Emergency Intervention: Facility staff have CPI training and do not use manual restraints on clients.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Emergency procedures are indicated on the form.

No deficiencies issued today. An exit interview was held and a copy of this report was given to the administrator.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2024
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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