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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603408
Report Date: 05/02/2024
Date Signed: 05/02/2024 04:03:51 PM

Document Has Been Signed on 05/02/2024 04:03 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:EASTERSEALS SOUTHERN CA - WEST MAPLE RESIDENCEFACILITY NUMBER:
198603408
ADMINISTRATOR/
DIRECTOR:		VAZQUEZ, LUDMILAFACILITY TYPE:
735
ADDRESS:9621 MAPLE STTELEPHONE:
(714) 834-1111
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 4CENSUS: 4DATE:
05/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:13 PM
MET WITH:Lori (Lorena) Bartolata - DSPTIME VISIT/
INSPECTION COMPLETED:
04:25 PM
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Licensing Program Analyst (LPA's) Tena Herrera and Daniel Konishi, conducted an unannounced visit for an Annual Inspection. LPA's met with (DSP) Lori Bartolata and explained the purpose for the visit. The facility is licensed to serve 4 Non-Ambulatory Adults ages 18 to 59 years old, of which 4 may be bedridden. The facility currently has 1 Ambulatory and 3 Non-Ambulatory clients.

This is a single- story facility located in a residential area in Bellflower, Ca. A tour of the facility includes: 4 bedrooms, 2 bathrooms, kitchen living room, dining area, attached garage with laundry, front/back yard.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility.
Physical Plant & Environment Safety: LPA toured facility, clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested in the client bathrooms and measured at 125.7 degrees F which is outside the required range of 105-120 degrees F details will be listed on the 809-D. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked cabinet and are inaccessible to clients. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged.
(Continued on 809-C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: EASTERSEALS SOUTHERN CA - WEST MAPLE RESIDENCE
FACILITY NUMBER: 198603408
VISIT DATE: 05/02/2024
NARRATIVE
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Operational Requirements: Staff have proper training to meet the needs of the clients in care. Facility has an activity area furnished for outdoor use. Last fire/earthquake drill was conducted on 10/1/23 which is not within the required quarterly drills.
Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the clients in the case of an emergency.
Personnel Records-Training: Staff files are maintained in a secure location. LPA reviewed 4 staff files during today’s visit, files reviewed contained the following: Criminal Background Clearance, First-Aid/CPR/AED and sufficient on-going training. Administrator Priscillah Houston certificate expires on 12/8/2024.
Client Rights-Information: Facility provides telephone landline and internet for the clients. Client rights posters and reporting posters are displayed within the facility.
Client Records-Incident Reports: Client files are maintained in a secured locked cabinet and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. LPA reviewed 4 client files with no issues.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Staff designated to administer medication have the proper annual training on file. Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers. Incidental Medical & Dental: All training is documented in the facility personnel files. Staff performance is reviewed annually, and documentation is maintained in the personnel files.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Facility maintains documentation of the required emergency drills with last drill on 2/10/24.
Emergency Intervention: Clients at this facility do not need the use of restraints or de-escalation techniques.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during todays visit will be documented on the 809-D.

Exit interview was held and a copy of the report was given to Administrator Priscillah Houston.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024
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Document Has Been Signed on 05/02/2024 04:03 PM - It Cannot Be Edited


Created By: Tena Herrera On 05/02/2024 at 03:42 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: EASTERSEALS SOUTHERN CA - WEST MAPLE RESIDENCE
FACILITY NUMBER: 198603408

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as during facility tour LPA tested water temperature in both client bathroom sinks and they both measured at 125.7 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2024
Plan of Correction
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Administrator/Licensee lowered water heater temperature during visit, and will create a water temperature log testing both client restroom sinks 3 times a day for the next 5 days, readings must be within the required reading of 105-120 degrees F and documented on log. Water temperature log to be submitted to LPA via email by 5/9/2024. Log shall begin on 5/4/24 and end on 5/8/24.
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:David Sicairos
LICENSING EVALUATOR NAME:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024


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