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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603408
Report Date: 06/29/2022
Date Signed: 06/29/2022 10:41:31 AM

Document Has Been Signed on 06/29/2022 10:41 AM - 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 CA - WEST MAPLE RESIDENCEFACILITY NUMBER:
198603408
ADMINISTRATOR:VAZQUEZ, LUDMILAFACILITY TYPE:
735
ADDRESS:9621 MAPLE STTELEPHONE:
(714) 834-1111
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 4CENSUS: 0DATE:
06/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Administrator Sophesias JohnsonTIME COMPLETED:
10:50 AM
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On 6/29/2022 at 9:10 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced visit for the purpose of conducting the required annual inspection. On today's visit LPA met with Easter Seals Associate, Priscillah Houston who assisted with the visit. Ms. Houston stated the facility is not open and has not received their first client. The facility is waiting on the regional center to modify their program design. There is no approx. date facility will receive their first client. At 10:25 Administrator Sophesias Johnson arrived and completed the visit with LPA

The Facility is licensed to served 4 clients between the age of 18 and 59 years old. 4 non ambulatory of which 4 can be bedridden. The facility is vendored through Harbor regional center. The facility is a single-story building in a residential area, with a commercial kitchen, dining room, living room, 4 bedrooms, 2 bathrooms, garage, and a back yard with shaded sitting area. Facility carbon monoxide/ smoke detectors were tested and in working condition.

All bedrooms have the required furniture including bedframes, dressers, lamps, and chairs. Beds have the required linen and the linen is in good condition. Passageways and exits are free of obstruction. The backyard is well maintained. The resident bathrooms are clean, and showers have non-skid materials. The facility temperature at the time the visit was comfortable. There is sufficient lighting throughout the facility. LPA observed a sufficient supply of PPE in garage. Infection control signs were observed throughout the facility.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2022
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 CA - WEST MAPLE RESIDENCE
FACILITY NUMBER: 198603408
VISIT DATE: 06/29/2022
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The facility needs to make sure the following things below is corrected before the first client move in:

· Water temperature is between 105-120 degrees F.
· The facility will have the required 7 days nonperishable and 2 days perishables.
· Facility will update information with new administrator.


No deficiencies were cited during the visit. Exit interview held and a copy of the report was provided to administrator Sophesias Johnson.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022
LIC809 (FAS) - (06/04)
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