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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601577
Report Date: 10/17/2023
Date Signed: 10/17/2023 03:28:24 PM

Document Has Been Signed on 10/17/2023 03:28 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:JORGE ROMEROFACILITY TYPE:
735
ADDRESS:357 VICTORIA PLTELEPHONE:
(818) 331-7138
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 4CENSUS: 4DATE:
10/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Jorge Romero- AdministratorTIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of conducting the required annual inspection, using the Compliance and Regulatory Enforcement (CARE) Tool, to evaluate the facility. LPA Maldonado met with facility Administrator, Jorge Romero and explained the purpose for the visit.

During today's visit, LPA Maldonado conducted a tour of the physical plant with Administrator, observed the facility food supplies, reviewed (4) client medications, (4) client files, (4) staff files, and conducted interviews with Staff# 1. LPA was unable to interview (4) clients due to clients being out in the community during the time of the visit. The facility is a single-story home, operating as an Adult Residential Facility, licensed to serve (4) developmentally disabled adults, ages 18-59. Facility has an approved fire clearance to serve (4) non-ambulatory clients. The home consists of a kitchen, living room, dining room, indoor activity area, (4) client bedrooms, (2) client bathrooms, attached garage with storage and laundry area, and a shaded patio with seating.

All client bedrooms were inspected and had the required furniture, storage space, and lighting. Bathrooms were equipped with a toilet, wash basin, and showers. They had the required grab bars and non-skid mats. The water was tested and measured at 113*F, which is in compliance. The food supplies was observed. The facility had (2) refrigerators and had the required 2-day perishables and 7-day non-perishables, as well as emergency food and water supplies available. (3) Fire extinguishers were observed, with current inspections and were fully charged. The home was in good repair and walkways/ramps were observed to be free of debris and obstructions/hazards. Sharps and toxins/cleaning supplies were observed stored in the garage, locked and inaccessible to clients in care. Centrally stored medications were also observed locked in a kitchen cabinet, inaccessible.

(Report Continued on LIC809-C...)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2023
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: 10/17/2023
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Laundry equipment was observed in good repair and operational during the visit. Sufficient linens, towels, and personal hygiene supplies were available. The facility has an approved mitigation plan on file and a current infection control plan submitted to the department. Sufficient PPE supplies were observed stored in the garage. Smoke/carbon monoxide detectors were observed in each room of the home, tested and operational during the visit. (4) Staff and (4) client files were reviewed for required documentation, and observed to be complete. (4) Client's medications were reviewed and observed to be documented properly and given as prescribed. Facility First Aid Manual and Kit were inspected and had the required items.

During today's visit, no deficiencies were observed or cited.

An exit interview conducted with Administrator. A copy of the report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023
LIC809 (FAS) - (06/04)
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