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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601577
Report Date: 01/02/2025
Date Signed: 01/02/2025 04:54:05 PM

Document Has Been Signed on 01/02/2025 04:54 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: 4DATE:
01/02/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:41 PM
MET WITH:Administrator- Jorge RomeroTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez and LPA Luis De Leon conducted a Case Management Visit-Incident on 01/02/2025, stemming from Special Incident Report received on 12/10/2024. LPA was greeted by House Manager- Nina Donini and explained the purpose of the visit. Administrator Jorge Romero arrived shortly after.

Case management- incident:

On 12/5/2024. S1 erroneously dispensed C1’s bedtime medication of Doxepin (25mg) & Diphenhydramine (50mg) during afternoon (3pm) medications pass. During bedtime medication pass (10pm), S2 dispensed an additional dose of Doxepin (25mg) & Diphenhydramine (50mg), that C1 already received earlier during afternoon (3pm) medication pass. S2 discovered their error and immediately notified Administrator Romero. Facility nurse, Community Care Licensing, C1’s primary physician and San Gabriel/Pomona Regional Center were notified on 12/6/2024. According to Administrator Romero, these medications were not PRN medications (as the need arises) but, scheduled medications that C1's primary physician ordered to be administered.



On 12/9/2024, S1 and S2 received 2 hours of in-service medications training. On 12/23/2024, S1 and S2 received a Performance Improvement Plan that documented their performance on 12/5/24 and action taken by the facility.

Based on records reviewed and interviews conducted, one (1) type A deficiency is being cited for violation of Title 22, Division 6, Chapter 1, Article 06. Continuing Requirements- 80065 Personnel Requirements- (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.

Exit interview was conducted and a copy of this report, 809-D and appeals rights was provided via email.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/02/2025
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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Document Has Been Signed on 01/02/2025 04:54 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 01/02/2025 at 01:53 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: 01/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/03/2025
Section Cited
CCR
80065(a)

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(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.
This requirement was not met as evidenced by:
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Licensee conducted re-training on 12/9/24 with S1 and S2. This clears 24hr POC. No further action is required.
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S1 & S2 erroneously dispensed C1 medication on 12/5/24 and did not follow C1's client needs according to C1's scheduled prescription medication orders.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/02/2025


LIC809 (FAS) - (06/04)
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