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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601577
Report Date: 02/14/2025
Date Signed: 02/14/2025 12:50:45 PM

Document Has Been Signed on 02/14/2025 12:50 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
GREATER LA AC/SC, 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: 3DATE:
02/14/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:52 AM
MET WITH:Administrator Jorge RomeroTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On 02/14/2025, Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Case Management Incident visit regarding the unexpected death of client#1 (C1) on 02/10/2025. LPA Ramirez was greeted by Administrator Jorge Romero and explained the purpose of the visit.

On 12/10/2025, LPA Ramirez received an Incident Report regarding the unexpected death of C1. On 1/24/2025, staff was performing routine vital signs check on clients and noticed C1’s oxygen levels were low. Staff re-checked C1’s vitals and determined emergency services were required and staff called 911. C1 was transported via ambulance to Montclair Hospital and C1 was admitted. On 2/8/2025, C1 was placed on hospice care and on 2/10/2025, C1 passed away.

LPA Ramirez requested a copy of C1 Death Certificate and hospice documents. LPA Ramirez obtained copies of C1’s face sheet, centrally stored medications and destruction log, medications administration record for 11/2024. 12/2024, and 1/2025, physician’s orders, Individual Program Plan (IPP), and physician’s report. LPA Ramirez may return at a later time to gather more documents in regard to this visit.

No deficiencies were observed during this visit. Exit interview was conducted. A copy of this report was provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2025
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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