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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602388
Report Date: 05/23/2023
Date Signed: 05/23/2023 03:08:53 PM

Document Has Been Signed on 05/23/2023 03:08 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 MOUNTAIN VIEWFACILITY NUMBER:
198602388
ADMINISTRATOR:TREVIZO-REINOSO, GUADALUPEFACILITY TYPE:
735
ADDRESS:3799 MOUNTAIN VIEW AVETELEPHONE:
(818) 512-2494
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 4CENSUS: 4DATE:
05/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:01 PM
MET WITH:Massoumeh Ho - LVN TIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE tool. LPA Flores met with Masoumeh Ho - LVN and explained the reason for the visit. Administrator arrived 30 minutes later.

Facility is licensed to serve 4 clients age range 18 through 59, of which 4 may be non-ambulatory and/or bedridden. The single home is located in a residential facility and consist of 4 client bedrooms, 3 bathrooms, a kitchen, a living room, a dining room, an office, a laundry area, a back yard, a front yard, and a detach garage.

LPA Flores conducted a tour of the facility with Masoumeh Ho - LVN and observed the following:
Facility is in good repair inside and outside. No large bodies of water were observed. Smoke/Carbon Monoxide detectors were tested and in working condition. Living room and dining room have a fireplace glass covered. Kitchen area is clean. Sharps and cleaning supplies were observed locked under the sink. Facility has sufficient food supplies for at lest 2 days of perishables and 7 days of non-perishables. Medication cabinets were observed locked. Each clients bedroom is in good repair, with sufficient lighting, required furniture and bedding. Bathrooms were observed in good repair and water temperature was tested between 111.1 and 115.5 which is within the required water temperature. Back yard has a shaded sitting area. Fire extinguisher was observed and last inspected on 6/1/22.
LPA Flores reviewed medication and files for 4 residents and 5 staff files. Administrator certificate was observed for Andres Rojas #6058196735 exp. date: 9/15/23. Emergency disaster plan version (LIC 610D 10/03) which is not the required current version LIC 610D 12/21. LPA conducted interviews with clients and staff.

Deficiency was noted on LIC 809D per Title 22 regulations. Exit interview was conducted with Andres Rojas Administrator and a copy of report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2023
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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Document Has Been Signed on 05/23/2023 03:08 PM - It Cannot Be Edited


Created By: Mary G Flores On 05/23/2023 at 02:53 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 MOUNTAIN VIEW
FACILITY NUMBER: 198602388

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based record review, the licensee did not comply with the section cited above in LIC 610D 10/03 was reviewed and facility does not have current version LIC610D which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2023
Plan of Correction
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Administrator will submit LIC 610D (12/21) to the department by POC due date 6/2/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2023


LIC809 (FAS) - (06/04)
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