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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601577
Report Date: 10/07/2022
Date Signed: 10/07/2022 10:28:42 AM

Document Has Been Signed on 10/07/2022 10:28 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
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:
10/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Jorge RomeroTIME COMPLETED:
10:45 PM
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Licensing Program Analyst (LPA) Christine Wong conducted an unannounced annual required visit. LPA met with DSP Ruth Rojas and explained the reason for the visit. Shortly after, the administrator Jorge Romero arrived and assisted with the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed clients' medications, observed food supply, and reviewed clients and staff files.

The facility is a single story house and located in a residential neighborhood area. The facility includes living room, dining area, kitchen, staff office, four clients bedrooms, two bathrooms and an attached garage. All 4 client bedrooms were toured. Each bedroom has one bed, one chair, one drawer, required bed linen and furniture and sufficient lighting and closet space. All two bathrooms were toured and they are clean, sanitary and in a good working condition. LPA tested the hot water temperature in both two bathrooms and it was measured between 107 and 112.7 degrees F which is within Title 22 regulation. The refrigerator in the kitchen and garage and the kitchen cabinet has sufficient 2 days perishable and 7 days non-perishable food supply. All the appliances are clean and working properly. The common area such as living room and dining area are clean and have the required furniture. The front and back yard are maintained well and the back yard has a shaded area with table and chairs for client to utilized. All the cleaning supplies and toxic and the sharp utensils and knives are locked in the cabinet located in the garage. LPA also inspected the smoke detectors and carbon monoxide detectors and they are working properly.

LPA reviewed 3 clients files and all their emergency contact information are updated. LPA also reviewed 2 staff files and they are all finger print cleared and the health screening forms are updated in the staff personnel file. LPA also inspected the 3 clients' medications and all seemed accurate and updated.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 VICTORIA
FACILITY NUMBER: 198601577
VISIT DATE: 10/07/2022
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Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, disinfecting products are available in each bathroom and common area and facility is disinfected every shift, all the bathrooms have sufficient soap, paper towels, and signs, PPE supplies are sufficient for more than 30 days.

No deficiencies were observed during the visit.

Exit Interview conducted. A copy of the report was provided to the administrator Jorge Romero
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
LIC809 (FAS) - (06/04)
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