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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603754
Report Date: 05/16/2024
Date Signed: 05/16/2024 10:49:20 AM

Document Has Been Signed on 05/16/2024 10:49 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:EASTERSEALS - SIERRA ROSE RESIDENCEFACILITY NUMBER:
198603754
ADMINISTRATOR/
DIRECTOR:		ERNESTO VASQUEZFACILITY TYPE:
735
ADDRESS:3053 1/2 E DEL MAR BLVDTELEPHONE:
(818) 512-2494
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 6CENSUS: 0DATE:
05/16/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:41 AM
MET WITH:Guadalupe Trevizo - ApplicantTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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Licenisng Program Analysts (LPA)s Mary Flores and Daniel Konishi conducted an announced pre-licensing visit at the facility. LPAs met with Guadalupe Trevizo, Ernesto Vasquez- applicants, Yadira Jasso and Nicole Snyder Easter Seals representatives were present.

The facility has an approved fire clearance for six (6) non-ambulatory clients between the age of 18 -59 years old, of which all may be bedridden. The facility consist of six (6) client bedrooms, three (3) bathrooms, a living room, a kitchen, a dining room, a laundry room, and a garden area.

LPAs toured the facility with Guadalupe Trevizo and Ernesto Vasquez and observed the following:
Facility is in good repair indoor and outdoor. Living room is fully furnished. Kitchen area is clean, in good repair, dishes and utensils were observed. Food supplies were observed for at least 2 days of perishables and 7 days of non-perishables. Refrigerator's temperature was observed at 35 degrees F., and freezer's temperature was observed at 0 degrees F. Closet's in the hallway across the laundry room will be use to stored sharps, medication, cleaning supplies and client files. Dining room was observed furnished.
Laundry area was observed with locking cabinets for items that will be inaccessible to clients. Licensing posters, Let us Know (PUB 745), clients' personal rights were observed in a board in the laundry room.
A total of 6 client bedrooms were observed, each has the required furniture; a bed, a chair, a chest drawer, a night stand, and bedding supplies. Additional bedding supplies and grooming supplies were observed in each of the client's closets. Bedrooms #1-#4 have an exit door.

Bathrooms were observed, 2 out of the 3 bathrooms are full bathrooms. Each is in working condition, showers were observed with grab bars and skid mats. Water temperature was tested between 107.7 and 108.3 degrees F., which is within the required temperature of 105-120 degrees F.

Two storage sheds are located in the back of the house. Garden area is clean and a shaded seating area is located outside the dining area. (CONTINUED ON LIC 809C)
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2024
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: EASTERSEALS - SIERRA ROSE RESIDENCE
FACILITY NUMBER: 198603754
VISIT DATE: 05/16/2024
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First aid kit was reviewed and has a scissor, twicers, bandages, gauze, a current manual, thermometer, band-aids. Fire extinguishers are located in the kitchen and hallway to the bedrooms and last checked on 1/30/24. Carbon Monoxide/Smoke detectors were tested and in working condition. Facility has a fire sprinkle system throughout.

Emergency Disaster Plan and Infection Control Plan were reviewed during this visit.

Component III was not reviewed during this visit as applicant has other licensed facilities and is familiar with component III.

The facility meets Title 22 Regulations.

Exit interview was conducted with Guadalupe Trevizo and Ernesto Vasquez and a copy of this report was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
LIC809 (FAS) - (06/04)
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