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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602857
Report Date: 08/17/2023
Date Signed: 08/17/2023 12:39:07 PM

Document Has Been Signed on 08/17/2023 12:39 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:EASTERSEALS SOUTHERN CALIFORNIA-MAPLE RESIDENCEFACILITY NUMBER:
198602857
ADMINISTRATOR:NJOROGE, PRISCILLAHFACILITY TYPE:
735
ADDRESS:10116 MAPLE STREETTELEPHONE:
(818) 512-2494
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 3CENSUS: 3DATE:
08/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Administrator Priscillah NjorogeTIME COMPLETED:
12:52 PM
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On 8/17/23 at 8:50 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual/Required inspection to Easter Seals Southern California Maple Residence. Upon arrival LPA was greeted by Direct Support Professional (DSP) Solange Dada who contacted the Administrator. The Administrator Priscillah Njoroge arrived at 9:30 a.m. and LPA explained the reason for the visit. This home is licensed to serve age range 18 through 59. (3) Non-ambulatory, of which (1) may be bedridden. The facility is vendorized through Harbor Regional Center. There were (2) clients in care during the time of this visit. The last emergency disaster/fire drill was conducted on 7/22/2023. The Administrator Certificate expired on 12/28/2022 #6014168735. LPA checked CDSS website and observed the administrator certification is currently on the pending list. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, reviewed (4) staff files, (3) resident files, medications, medication administration records for (3) residents and there PNI records.

This home contains 2 bedrooms, 1 bedroom with covered fireplace, 2 bathrooms, office, living room, dining room, laundry room, kitchen, game room with covered fireplace and a detached garage. LPA toured the physical plant with the Administrator, and observed all (3) client bedrooms, contained required furniture, lamps, dresser, chair, and closet space. The two bathrooms contain a working toilet, basin and water faucet, walk in shower with grab bar, and shower chair. The temperature measured at 115.1*F-116.7*F. The smoke detectors were battery operated, tested, and observed to be working properly. The carbon monoxide detector is located in the hallway, tested, and functioning properly. There were (2) fire extinguishers located in kitchen and garage fully charged and up to date. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans. The knives were secured/locked with medications. The pantry was well stocked with canned goods, pasta, cereals, and the food supply contained a sufficient supply with a two-day supply of perishables and a seven-day supply of non-perishables that met title 22 guidelines. Walls and floors, cabinets and counters were clean and sanitary throughout the home.
(Report continued on LIC809C.)
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: EASTERSEALS SOUTHERN CALIFORNIA-MAPLE RESIDENCE
FACILITY NUMBER: 198602857
VISIT DATE: 08/17/2023
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The outdoor grounds were toured and inspected, and the patio was well maintained with a shaded seating area accessible for client use. The garage was divided into (2) areas and contained emergency food supplies, toiletries, personal care supplies, and toxins and cleaning agents stored locked and inaccessible to the clients.

Exit interview conducted with Priscillah Njoroge, Administrator, a copy of this report was provided, and Appeal rights given.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023
LIC809 (FAS) - (06/04)
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