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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601577
Report Date: 11/08/2021
Date Signed: 11/08/2021 02:49:12 PM

Document Has Been Signed on 11/08/2021 02:49 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:EASTER SEALS SOUTHERN CALIFORNIA VICTORIAFACILITY NUMBER:
198601577
ADMINISTRATOR:SOPHESIAS JOHNSONFACILITY TYPE:
735
ADDRESS:357 VICTORIA PLTELEPHONE:
(818) 331-7138
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 4CENSUS: 3DATE:
11/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Facility Administrator TIME COMPLETED:
02:15 PM
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  • Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Facility Administrator and explained the purpose of today's visit. LPA toured the facility grounds.

This home consists of (4) bedrooms, 2 full-bathrooms, office, dinning area, kitchen, living room and an attached garage. There are (3) clients residing at this home. (2) out of (3) clients are over the age of 59. Per Facility Administrator an age exemption was submitted to CCLD Monterey Park Office and will follow up with the status. LPA provided Facility Administrator with Title 22, Section 85068.4 Acceptance and Retention Limitations regulations.

The following were observed/inspected:
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility, in all common rooms and hallways.
  • Signs are posted to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • All Clients have their own private bedroom.
  • Medication reviewed for (3) Clients (Client #1 through Client #3).
  • Per Administrator, all (3) clients are fully vaccinated. Facility Administrator to follow up on the COVID Booster.
  • PPE supplies observed. They are stored inside the garage. Hygiene supplies are stored inside the garage. All common areas including entrances have a hand sanitizers.
  • Staff responsible for direct care and supervision were observed wearing masks.
  • Clients were socially distanced according to local public health guidelines.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed.

Exit interview conducted, a copy of this report and Appeal Rights were provided to Facility Administrator
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2021
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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