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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601577
Report Date: 09/14/2024
Date Signed: 09/14/2024 10:49:17 AM

Document Has Been Signed on 09/14/2024 10:49 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:EASTER SEALS SOUTHERN CALIFORNIA VICTORIAFACILITY NUMBER:
198601577
ADMINISTRATOR/
DIRECTOR:		JORGE ROMEROFACILITY TYPE:
735
ADDRESS:357 VICTORIA PLTELEPHONE:
(818) 331-7138
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 4CENSUS: 4DATE:
09/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:05 AM
MET WITH:DSP Ruth RojasTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met DSP worker Ruth Rojas at approximately 8:00 AM and explained reason for visit. Administrator Jorge Romero arrived shortly.

Facility is licensed to serve four (4) developmentally disabled adults, ages 18-59. Four can be non-ambulatory. All clients residing at this receive Case Management services provided by San Gabriel Pomona Regional Center. The facility is in a residential area, and it is a one-story family home. A tour of the facility included the living room, dining room, kitchen, 4 client bedrooms, 1 office, 2 bathrooms, front yard, backyard, and attached garage.

LPA toured the facility and observed the following: Each client bedroom has the required furniture and bedding. There is extra clean linen and towels in each client’s room and also in garage. Smoke detectors/carbon monoxide detectors were observed in each room and throughout the facility and are properly operating. The facility has three (3) fully charged fire extinguishers which are kept in kitchen, hallway, and garage. Cleaning supplies, knives, and toxic substances are inaccessible to clients in a locked storage in garage. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 45 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. There is an extra refrigerator in garage with more food. There are no firearms or weapons stored at the facility. 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 hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction.


SEE LIC 809C
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA VICTORIA
FACILITY NUMBER: 198601577
VISIT DATE: 09/14/2024
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Four (4) staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Four (4) client files were reviewed and included physicians report, TB clearance, and individual program plan (IPP)report. Last fire/earthquake drill was conducted in July of 2024. Infectious control plan was reviewed. Four (4) client medications were reviewed. Medications are centrally stored and locked MAR log is used.

No deficiency was observed during today’s visit. Exit interview was conducted with Administrator Romero and a copy of report was provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2024
LIC809 (FAS) - (06/04)
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