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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602387
Report Date: 03/26/2024
Date Signed: 03/26/2024 03:27:15 PM

Document Has Been Signed on 03/26/2024 03:27 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 ORANGE GROVEFACILITY NUMBER:
198602387
ADMINISTRATOR:CHINAKA, LOVEDAYFACILITY TYPE:
735
ADDRESS:1657 E ORANGE GROVE BLVDTELEPHONE:
(818) 512-2494
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 4CENSUS: 4DATE:
03/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Ernesto Vasquez - Program Director
Saundra Sahagun - Administrator		TIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required 1-yr visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Luis Hernandez, Direct Care Staff I & II (DSP I & II) and explained the purpose of the visit. At 1:15pm, Ernesto Vasquez, Program Director arrived and Saundra Sahagun, Administrator arrived at 1:35pm, both assisted LPA with the inspection. The facility is licensed to care for (4) Developmentally Disabled Adults, ages 18 through 59, non-ambulatory of which (1) may be bedridden. 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:
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. There is a visitor sign-in station located at the entrance on the the side front door. LPA observed a staff using disposable gloves while cleaning and disinfecting the high touched surfaces in the kitchen area. Staff stated they use gloves when handling food and assisting with medication. 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, family room, backyard and a detached garage. Currently, there are four (4) clients living in the facility. Facility is a Specialized Home. 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 are two (2) fire extinguishers observed to be fully charged and mounted on the wall near the front door and 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. Facility has a video camera monitor system in the common areas, front yard and back yard. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. At 1:45pm, water supply measured at 112.6 deg F in bathroom #1, and 114.8 deg F in bathroom #2.
Operational Requirements: A current Plan of Operation was reviewed. Surety Bond is in effect and in force with bond amount of $6000. Fire & earthquake drills with staff were last conducted on 3/17/2024. ****REPORT CONTINUED ON LIC809-C*****
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2024
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 ORANGE GROVE
FACILITY NUMBER: 198602387
VISIT DATE: 03/26/2024
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Staffing: A total of ten (10)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: Reviewed files for three (3) staff. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator certificate is valid and will expire on 04/04/2024. Administrator's first aid certificate expired on 3/10/2024, and scheduled for first aid training on Fri., 3/29/2024.
Client Rights-Information: Client personal rights are posted. Per Administrator, facility provides internet services to all clients and have access to the facility phone. None of the clients have their own personal cell phone and (3) out of (4) clients have their own tablet. LPA was not able to interview the clients. (2) clients are out in the Day Program and (2) clients are non verbal.
Food Service: There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator. There are (2) clients with special diets residing at this facility. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.
Client Records-Incident Reports: LPA reviewed Client files for C1 through C4. Client files are maintained at the facility. Physician's Report (including TB and 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.
Health Related Services: The medications are centrally stored and in their original containers. Medications were reviewed for C1-C4 to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubbled packed.
Incidental Medical Services: Per the Administrator, there is (1) client at this home with restricted health condition.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan. Emergency Intervention: Not applicable.

Technical assistance issued. Exit interview held and a copy of this report was provided to Saundra Sahagun, Administrator.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024
LIC809 (FAS) - (06/04)
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