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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601656
Report Date: 02/08/2023
Date Signed: 02/08/2023 12:23:35 PM

Document Has Been Signed on 02/08/2023 12:23 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 EASTLYN RESIDENCEFACILITY NUMBER:
198601656
ADMINISTRATOR:JORGE ROMEROFACILITY TYPE:
735
ADDRESS:1299 EASTLYN PLTELEPHONE:
(626) 791-1597
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 4CENSUS: 4DATE:
02/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Kirsten PouriTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced annual inspection focusing on the Infection Control Domain. LPA was allowed entry into this home by Christina Gonzalez, Direct Support Professional II (DSP II) and discussed the purpose of today's visit. The facility is licensed to serve four (4) non-ambulatory clients ages 18-59. Current client census is (40. At 10:25am, Administrator Kirsten Pour arrived and assisted LPA Pena with the inspection. LPA toured the facility, observed the COVID-19 procedures, reviewed clients' medications and observed food supplies. This single-story home contains four (4) bedrooms, two and a half (2 1/2) bathrooms, a living room, kitchen, dining area, backyard, and attached garage.

The following was observed/inspected:
  • The facility had a universal entrance screening area including a thermometer, PPE supplies, screening logs, and sign-in sheet.
  • COVID-19 signage was placed in several areas of the facility.
  • Staff wore face masks throughout their shift.
  • Facility maintained a 30-day supply of PPE stored in the supply closet in the garage.
  • The laundry room is located in the garage, it is clean and has cleaning supplies inaccessible to residents.
  • At 10:35am, the kitchen was inspected. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. All the appliances are clean and are working properly.
  • Cleaning solutions and kitchen knives/sharps were locked and inaccessible.
  • Hot water temperature was measured in the kitchen and (3) bathrooms. Kitchen was measured at 115.3 deg F, bathroom #1 read at 116.1 deg F, bathroom #2 at 114.8 deg F and bathroom #3 at 116.4 deg F which are all within the required 105 - 120 degrees.
  • Clients' bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, night stand, light, chair and sufficient closet space.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2023
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA EASTLYN RESIDENCE
FACILITY NUMBER: 198601656
VISIT DATE: 02/08/2023
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  • Bathrooms have the required grabs bars, non-skid materials and contained hygiene supplies including liquid soap, paper towels, and toilet paper.
  • Medications were locked, centrally stored, and given as prescribed. Medications were reviewed for all (4) clients and confirmed that medication is given as prescribed and is documented properly.
  • The common areas such as activity room and dining room are clean and have the required furniture. Furniture and group activities were spaced to encourage physical distancing.
  • The backyard has a shaded area and sitting area. The backyard has been designated as the visitor area during the COVID-19 pandemic.
  • Exit doors have auditory devices that were operating at the time of the visit. There are cameras outside of the property, back yard and front yard. There were no cameras seen inside the home.
  • Smoke detectors/carbon monoxide detectors were present and operable.
  • Two (2) fire extinguishers were observed to be fully charged and last serviced on June 1, 2022. The fire extinguishers were in the kitchen and the garage.
  • Staff and Clients files were not reviewed during this visit.
  • Administrator certificate expired in Nov. 22, 2022. Administrator applied for the renewal and submitted it on Dec. 12, 2022, but has not received the actual Administrator certificate as of yet. Proof of the pending renewal application was provided to LPA during the visit.

There were no deficiencies cited at this time. An exit interview was conducted, and a copy of this report and appeal rights were provided to the Administrator, Kirsten Pouri.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023
LIC809 (FAS) - (06/04)
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