198602387-4-10-2026-28-AS-MCOA-DSZQWD-20260410123145

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602387
Report Date: 04/10/2026
Date Signed: 04/10/2026 12:33:02 PM

Document Has Been Signed on 04/10/2026 12:33 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 ORANGE GROVE		FACILITY NUMBER:	198602387
ADMINISTRATOR/ DIRECTOR:	CHINAKA, LOVEDAY		FACILITY TYPE:	735
ADDRESS:	1657 E ORANGE GROVE BLVD		TELEPHONE:	(818) 512-2494
CITY:	PASADENA	STATE: CA	ZIP CODE:	91104
CAPACITY: 4		CENSUS: 4	DATE:	04/10/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Ernesto Vazquez, Adminstrator		TIME VISIT/ INSPECTION COMPLETED:	12:45 PM

NARRATIVE

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Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced annual inspection today. Luis Hernandez, Direct Support Staff, and the reason for the visit was explained. Administrator, Ernesto Vasquez, Director, arrived thereafter and continued to facilitate today’s visit.

The facility is licensed to serve (4) developmentally disabled adults ages 18 to 59; (4) non-ambulatory of which (1) may be bedridden. The facility is operating within the scope of its license. The facility is currently providing services to clients through the Frank D. Lanterman Regional Center.

The single-story home is in a residential area of Pasadena, and it consists of (2) living room areas, staff office, (4) client bedrooms, (2) full bathrooms, laundry room, detached garage and front and backyard.

The following was observed during visit:

The facility was observed clean inside and out. Walkways, passageways, ramps and exits are kept clear of debris and obstructions. Furniture is clean and in good repair. Living room and dining area have sufficient seating for staff and clients. The kitchen was observed clean and appliances were operating properly. The facility has sufficient 2-day perishable and 7-day perishable supply of food. Sharps/knives, cleaning supplies and other toxins are kept locked in the kitchen island. Bedrooms have all the required furniture, bedding and adequate lighting. Bathrooms were also observed clean and sanitary. Water temperature was tested in both bathrooms and measured between 105 – 120 degrees F. which is within the compliance range. Bathrooms have safety grab bars and non-skid surfaces. The laundry room is kept clean, and appliances are in operating condition.

***Continues on LIC 809-C****

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/10/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2026

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 04/10/2026 12:33 PM - It Cannot Be Edited

Created By: Mayra Cota On 04/10/2026 at 12:16 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 ORANGE GROVE	FACILITY NUMBER: 198602387
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80075(f)

(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 3 staff's First Aid/CPR certification has expired, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/27/2026
	Plan of Correction
1 2 3 4	Licensee will email LPA, current certification for Staff 1 and Staff 2 by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

	Mayra Cota
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/10/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2026

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 ORANGE GROVE	FACILITY NUMBER: 198602387
	VISIT DATE: 04/10/2026

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Front and backyard are kept clean and garden is maintained. The backyard has a shaded patio area and patio furniture is in good repair. No pools or bodies of water were observed. The garage was observed free of clutter. Facility has extra supply of incontinence care and cleaning supplies readily available for use. The home has (2) fire extinguishers, charged and operable, and were last inspected on 4/11/2025. Combination smoke and carbon monoxide detectors were tested during visit and were operating properly. The facility conducts safety drills every month. Last safety drill was conducted on 2/19/2026, with client and staff participation. Emergency and Disaster Plan was reviewed and is up to date. Medications are centrally stored and inaccessible to clients in care. Medications were observed to be dispensed according to physician orders and documented accordingly. Four (4) client and (3) staff files were reviewed. Staff 1 and Staff 2 have First Aid/CPR certification which has expired. File for Client 1 contains the appropriate Restricted Health Conditions Plans and Age Exception. However, Client 1 and Client 3 are missing current Physician Reports forms. Review of Record of Health Care Visit form indicates that C1 and C3 have been seen by a doctor for their physicals on 1/12/26 and 2/19/26, but the facility does not have the complete forms in clients’ files.

Deficiencies noted and a citation is being issued. A Technical Violation was also created. Exit interview was conducted with Ernesto Vasquez, Director, and a copy of this report, LIX 809-D and was provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/10/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2026

LIC809 (FAS) - (06/04)

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