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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602008
Report Date: 10/10/2024
Date Signed: 10/11/2024 02:13:53 PM

Document Has Been Signed on 10/11/2024 02:13 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:EASTER SEALS SOUTHERN CALIFORNIA REDONDO BEACHFACILITY NUMBER:
198602008
ADMINISTRATOR/
DIRECTOR:		DEVINE, KIMFACILITY TYPE:
775
ADDRESS:3007 VAIL AVETELEPHONE:
(310) 849-3332
CITY:REDONDO BEACHSTATE: CAZIP CODE:
90278
CAPACITY: 30CENSUS: 11DATE:
10/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Shavon Starks, Program CoordinatorTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On 10/10/2024 at 8:35am, Licensing Program Analysts (LPA) Zina Brown made an unannounced visit to the above facility. The purpose of today's visit was to conduct an annual inspection of the facility. On today's visit LPA met with facility Program Director Shavon Starks. The facility profile shows that the facility is licensed for a capacity of (30). The Program Director stated that the facility has (10) clients currently enrolled in the program: (9) ambulatory and (1) non-ambulatory. The staff to client ratio is (1) one staff to (6) six clients. Program Director stated none of the clients have restricted health care conditions or utilize any protective devices. The last disaster drill was conducted and on file 08/08/2024. The program does not provide transportation. The facility fee owe a balance of $152 due 12/01/2024.

As a part of today's inspection LPA reviewed (10) client records, (5) staff records, (0) medication administration records and inspected the physical plant. The facility is a commercial 1 story structure located in a commercial district. The facility is next to a public park. The facility consists of the following: a parking lot (drop off/pick up area),lobby with reception area, main activity room, 2 restrooms (men and women), 1 office, second large activity room with kitchenette (which the day program utilizes), kitchen (water temperature measured at 125.4F), storage closets, and shaded back yard with tables and chairs.

At 11:03am, LPA conducted a tour of the physical plant and observed the following: walls and floors were in good condition, adequate lighting and fire extinguishers were properly charged. LPA observed plenty of storage space and chemicals were properly locked. The restrooms were clean and within Title 22 regulations. The kitchen was clean and a refrigerator was available for client use. The day program does not provide lunch nor snacks for clients. The first aid kit was available and fully stocked. Walkways throughout the day program and all exits were clear of hazards and debris.

Report continues on LIC 809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2024
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA REDONDO BEACH
FACILITY NUMBER: 198602008
VISIT DATE: 10/10/2024
NARRATIVE
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LPA observed the following not in compliance:
On 10/10/2024, LPA reviewed, 3 out of 5 staff files and observed no criminal record association at the time of visit.

On 10/10/2024, LPA conducted a file review of the 3 out of 10 client files and did not observe an Needs and Services Plan within 30 days after admission date.

Civil Penalty assessed.

Deficiencies Cited Under California Code of Regulations Title 22, Division 6, Chapter 3.


Exit interview conducted and a copy of the appeal rights were given.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/11/2024 02:13 PM - It Cannot Be Edited


Created By: Zina Brown On 10/10/2024 at 01:01 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA REDONDO BEACH
FACILITY NUMBER: 198602008

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82019(e)
Criminal Record Clearance
(e) Prior to working, residing or volunteering in a licensed day program, all individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall do the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, staff Shavon Starks, Julia Oshiro, and Maria Reynoso was not associated to the facility as the time of unannouced inspection which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/11/2024
Plan of Correction
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The facility shall associate staff in Guardian and submit proof of update via email zina.brown@dss.ca.gov 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.
SUPERVISOR'S NAME:Janae Hammond
LICENSING EVALUATOR NAME:Zina Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/11/2024 02:13 PM - It Cannot Be Edited


Created By: Zina Brown On 10/10/2024 at 01:01 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA REDONDO BEACH
FACILITY NUMBER: 198602008

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068.2(d)(1)
Needs and Services Plan
(d) If the client has an existing needs appraisal or individual program plan (IPP) completed by a placement agency, or a consultant for the placement agency, the Department may consider the plan to meet the requirements of this section provided that: (1) The needs appraisal or IPP is not more than one year old.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the facility did not comply with the section cited above for 3 out of 10 clients which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2024
Plan of Correction
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The facility submit proof of needs and appraisal plan for client #3, client #5, and client # 7 via email zina.brown@dss.ca.gov 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.
SUPERVISOR'S NAME:Janae Hammond
LICENSING EVALUATOR NAME:Zina Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2024


LIC809 (FAS) - (06/04)
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