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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601656
Report Date: 07/07/2025
Date Signed: 07/07/2025 04:39:33 PM

Document Has Been Signed on 07/07/2025 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 EASTLYN RESIDENCEFACILITY NUMBER:
198601656
ADMINISTRATOR/
DIRECTOR:		JORGE ROMEROFACILITY TYPE:
735
ADDRESS:1299 EASTLYN PLTELEPHONE:
(626) 791-1597
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 4CENSUS: DATE:
07/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:54 PM
MET WITH:Saundra Sahgun, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Blanca Gonzalez and Licensing Program Manager (LPM) Adeline Ho conducted an unannounced visit at the facility for the purpose of the required 1-year inspection. LPA and LPM met with Caregiver Marcia Lopez and explained the purpose of the visit. Administrator Saundra Sahagun and Director Ernesto Vasquez arrived shortly after.

The facility is licensed to serve four (4) non-ambulatory clients ages 18-49.

All clients residing at this facility receive case management services provided by Frank D. Lanterman Regional Center. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

The facility is a single-story home located in a residential area of Pasadena. The home includes four (4) client bedrooms, two (2) common bathrooms, one (1) staff restroom, dining area, living area, kitchen and one attached car garage.

LPA observed client bedrooms had the required furniture and sufficient lighting, all in good repair.

Bathrooms have non-skid mats and contain hygiene supplies including liquid soap and toilet paper. Hot water temperature was tested and measured at 112.4 degrees F and 110 degrees F, which is within range of 105 – 120° F.

Report continued on 809C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2025
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 07/07/2025 04:39 PM - It Cannot Be Edited


Created By: Blanca Gonzalez On 07/07/2025 at 03:36 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 EASTLYN RESIDENCE
FACILITY NUMBER: 198601656

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80076(a)(1)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan -Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.

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 which zucchini and strawberries dated 06/06/25 were found moldy and cucumbers stored in a bag were wet and soggy in the refrigerator which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/08/2025
Plan of Correction
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Administrator will train staff and present a rotation schedule to ensure food supply is checked on a regular basis. Administrator will submit an agenda and log of staff training to LPA and any new policies implemented.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Blanca Gonzalez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2025


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 EASTLYN RESIDENCE
FACILITY NUMBER: 198601656
VISIT DATE: 07/07/2025
NARRATIVE
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LPA observed combined smoke and carbon monoxide detectors were tested and are operable. Fire extinguishers located in the kitchen and in the garage are charged. Last emergency drill was conducted 03/24/2025. The facility has a complete Emergency Disaster Plan.

Fireplace in the living area is secured with glass and mesh screens. No firearms are stored at facility

7 days non-perishable food supplies were maintained. Two days perishable were observed in main refrigerator and garage refrigerator. Zucchini and strawberries were dated 06/06/25 and were moldy. Pesticides and cleaning supplies are kept away from the food preparation areas. There are no clients with special diets residing at this facility. Kitchen is kept clean and free from rodents and other bugs/insects. Plates, cups and utensils are kept cleaned and stored properly. Sharps are stored in a locked kitchen cabinet, inaccessible to clients.Passageways and exit doors are free of debris and obstruction.Centrally stored medications are kept in a cabinet and inaccessible to clients.

There is no swimming pool or body of water observed. Laundry area is in the detached garage. Disinfectants, cleaning solutions and laundry detergents are locked in storage cabinet in the garage. Outdoor shaded area with sufficient seating is available for clients.

LPA obtained copies of client and staff rosters. LPA reviewed files for four (4) clients (C1-C4). Client files are maintained at the facility. Physician's Report (including Ambulatory Status), Consent for Medical Treatment, Individual Program Plan (IPP), Behavioral Reports, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights observed. Based on record review,(2) out of (4) client files did not contain TB clearance which poses/posed a potential health, safety or personal rights risk to persons in care. LPA reviewed files four (4) staff (S1-S4). Staff files are maintained at the facility. Staff have current CPR/first aid training and sufficient on-going training that meets the annual requirement. Staff have their Health Screening and Tuberculosis Screening on file.

The required 1-yr visit is complete. Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies are cited today (see LIC 809-D).

Exit interview was held and a copy of this report was provided to the Administrator

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 07/07/2025 04:39 PM - It Cannot Be Edited


Created By: Blanca Gonzalez On 07/07/2025 at 04:13 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 EASTLYN RESIDENCE
FACILITY NUMBER: 198601656

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(a)

80070 Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in (2) out of (4) client files did not contain TB clearance which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2025
Plan of Correction
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Administrator will contact client's physcian's to obtain test results for C3 and C4 and submitt proof of TB clearance to LPA by POC due date
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Blanca Gonzalez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2025


LIC809 (FAS) - (06/04)
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