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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601656
Report Date: 05/31/2024
Date Signed: 05/31/2024 05:23:29 PM

Document Has Been Signed on 05/31/2024 05:23 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/
DIRECTOR:		JORGE ROMEROFACILITY TYPE:
735
ADDRESS:1299 EASTLYN PLTELEPHONE:
(626) 791-1597
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 4CENSUS: 3DATE:
05/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:55 PM
MET WITH:Saundra Sahagun - Administrator
Nicole Snyder - District Manager		TIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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Licensing Program Analysts (LPAs) Bennette Pena and Danile Konishi conducted an unannounced Required 1-yr visit. Upon arrival at 1:55pm, LPAs knocked at the door but no one answered. LPA contacted Saundra Sahagun on the phone and arrived shortly thereafter. At 2:45pm, Nicole Snyder arrived to assist LPAs with the inspection. The facility is licensed to care for (4) Developmentally Disabled Adults, ages 18 through 59, non-ambulatory only. All clients residing at this facility receive case management services provided by Frank D. Lanterman Regional Center. LPAs utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Staff are adhering to infection control requirements.
Physical Plant/Environment Safety: The facility is a single storey home located in a residential neighborhood, contains four (4) client bedrooms, two (2) full bathrooms, a living room with fireplace, kitchen, dining area, backyard and a detached garage. Currently, there are three (3) clients living in the facility. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, night stand, light, chair and sufficient closet space. Bathrooms have non-skid materials and contained hygiene supplies including liquid soap and toilet paper. Exit doors are free of any obstruction. Backyard was inspected and there were no debris or any obstructions. There is one (1) fire extinguisher observed to be fully charged, last serviced on 6/14/2023 and mounted on the wall in the kitchen area. Smoke alarms were tested and operable. There are no firearms or weapons stored at the facility. There is no swimming pool or body of water observed. Detached garage was inspected and LPAs observed additional PPE supplies and extra food supplies in the refrigerator. Laundry area is in the detached garage. Facility has a video camera monitor system without audio in the front yard and back yard. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Water supply measured at 117.3 deg F in bathroom #1, and 114.2 deg F in bathroom #2.
Operational Requirements: A current Plan of Operation was reviewed. A fire clearance is in place. Surety Bond is in effect and in force with bond amount of $6000. Liability Insurance is in place and valid. Emergency drill with staff was last conducted on 4/12/2024.
****REPORT CONTINUED ON LIC809-C*****
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2024
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
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: 05/31/2024
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Staffing: A total of eleven (11) staff members including the Administrator provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.
Personnel Records/Staff Training:
Client Rights-Information:
Food Service:
Client Records-Incident Reports:
Health Related Services:
Incidental Medical Services:
Disaster Preparedness:
Emergency Intervention

Exit interview held and a copy of this report was provided to Saundra Sahagun, Administrator.

***Due to time constraints, LPAs were not able to complete the annual inspection for this facility. LPA(s) will do a continuation of this inspection.***

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC809 (FAS) - (06/04)
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