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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601577
Report Date: 10/14/2025
Date Signed: 10/14/2025 04:39:48 PM

Document Has Been Signed on 10/14/2025 04:39 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
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:
10/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:19 PM
MET WITH:Jorge Romero TIME VISIT/
INSPECTION COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Analyst (LPA’s) Gabriela Castro and Christian Gutierrez conducted an unannounced required annual visit using the Compliance and Regulatory Enforcement (CARE) Tool. LPA was greeted by Nina Donini and explained the reason for the visit. Administrator Jorge Romero arrived shortly thereafter.

Facility is licensed to serve four (4) developmentally disabled adults, ages 18-59. Four (4) can be non-ambulatory. All clients receive case management services provided by San Gabriel Pomona Regional Center.

Facility Tour & Observations:

Personal Rights postings (LIC 613C and Ombudsman) were observed in a common area. Clients had access to personal space, privacy, and adequate storage. No firearms/weapons were present.

Physical Plant

The facility is in a residential area and is a one-story home consisting of 4 client bedrooms, living room, dining room, kitchen, 1 office, 2 bathrooms, front yard, backyard, and attached garage. Extra clean linens and towels were stored in clients’ bedrooms. Both bathrooms were equipped with working sinks, toilets, and showers, as well as the required grab bars and non-skid mats. Bathrooms had working fixtures, grab bars, and non-skid mats; hot water measured in bathroom (1) 121.1F and bathroom (2) 123.4 which are not within the required 105–120°F. Smoke/carbon monoxide detectors were functional, and a charged fire extinguishers (3) were available. Exits were clear, and no bodies of water were present. While conducting a walk through of the kitchen LPA observed a cockroach in the utensil drawer. Backyard provided shaded seating; garage contained laundry and locked storage for chemicals. Passageways and exits were observed to be clear and unobstructed.(Continued on 809C)

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Gabriela Castro
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 10/14/2025 04:39 PM - It Cannot Be Edited


Created By: Gabriela Castro On 10/14/2025 at 03:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA VICTORIA
FACILITY NUMBER: 198601577

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)(1)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in LPA observed a cachoroach in the kitchen drawer which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/15/2025
Plan of Correction
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Administrator agrees to contact a pest control service to asses the problem and provide treatment if needed. Administrator will send LPA a copy of the invoice as proof of correction on POC due date.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in 2 out of 2 restrooms water temperature read at BR #1 121.1F and BR#2 123.4F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/15/2025
Plan of Correction
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DSP staff adjusted water temperature at time of visit. Dificiency cleared at the time of visit.
Administrator agrees to create a water log for a week. Administrator will send LPA a copy of the water temperature log by 10/21/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Gabriela Castro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2025


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: 10/14/2025
NARRATIVE
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Food Service:
Refrigerators/freezers were maintained at proper temperatures (refrigerators maximum of 40 degrees F and freezer 0-degree F) with sufficient supply of 2-day perishable and 7 days non-perishable food. Fresh produce, proteins, and dry goods were stocked. There is an extra refrigerator in garage with more food. Knives and cleaning supplies are stored in garage cabinet, required to remain inaccessible to clients.

Health-Related Services & Records:
Four (4) client files were reviewed and contained current required documents (Admissions Agreements, Pre-Placement Appraisals, Consents, Needs/Service Plans, Physician’s Reports with TB/ambulatory status, Rights acknowledgments, and IPPs). Medical/dental care was current. Four (4) medications were reviewed; medications are required to be centrally stored in kitchen cabinet locked, and labeled. MAR logs were current.

Disaster Preparedness:
Last fire/earthquake drill was conducted on September 3, 2025 with logs available. LIC 610D Emergency Disaster Plan was posted in [insert location]. Emergency supplies (water, food, flashlights, batteries, first aid) were observed. Infection Control Plan was updated.

Personnel Records & Training:
Four (4) staff files were reviewed and included criminal record clearances, CPR/First Aid, DSP training, and TB screenings. Administrator Certificate for Jorge Romero was valid through November 16, 2025. Staffing ratio met requirements.

An exit interview was conducted with Jorge Romero, Administrator During the inspection, deficiencies were observed and cited on the attached LIC 809D/809C in accordance with Title 22, Division 6 regulations. The Administrator was advised of the nature of the deficiencies, the regulatory basis, and the required Plan of Correction (POC). The Administrator agreed to submit proof of correction by the due dates specified. A copy of this report, LIC 809D/809C, and appeal rights will be provided via email.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Gabriela Castro
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC809 (FAS) - (06/04)
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