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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603754
Report Date: 10/31/2024
Date Signed: 10/31/2024 12:40:30 PM

Document Has Been Signed on 10/31/2024 12:40 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 - 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: 6DATE:
10/31/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:06 AM
MET WITH:Herminia Gonzalez-Soto - Direct Support StaffTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced post-licensing visit at the facility using the CARE inspection tool. LPA met with Heminia Gonzalez - Soto and explained the reason for the visit.

The facility is licensed to serve 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, a family room, and a garden area.

LPA Flores conducted a tour of the facility with Herminia Gonzalez-Soto and observed the following:
Facility is clean and in good repair inside and outside. Living room, dining room were observed furnished. Kitchen was observed clean, in good repair, with sufficient food stored for at least 2 days of perishables and 7 days of non-perishables. Refrigerator/Freezer temperatures were observed within the recommended -40/0 degrees F. Cleaning supplies were stored/locked in the laundry area. Medication cabinets were observed locked in the hallway. A total of 6 client bedrooms were observed clean, with the required furniture, bedding supplies, and sufficient lighting. A client bedroom was converted into a living room, and a shared client bedroom was converted into two separate bedrooms. Building permits and facility's sketch were not submitted to the department prior construction. Three (3) bathrooms were observed clean in good repair, water temperature was tested in each bathroom between 111.0-130 degrees F. which is not within the required 105-120 degrees F. Passageways and exit doors are clear of debris and obstructions. Facility's yard has a covered seating area. No large bodies of water were observed. Facility has a fire sprinkler system throughout.

LPA reviewed 5 client files, medication, and P&I money, and 5 staff files.

(CONTINUED ON LIC 809C)
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2024
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: 10/31/2024
NARRATIVE
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LPA reviewed Emergency Disaster Plan and Infection Control procedures.

A change of administrator was notified to LPA on 9/18/24, assigning Joey Perez - Administrator Certificate #6055171735 exp. date: 12/7/24. During this visit LPA discussed documents that were missing to be submitted to the department and will be provided 11/7/24.

A deficiency is noted per Title 22 Regulations on LIC 809D.

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

DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/31/2024 12:40 PM - It Cannot Be Edited


Created By: Mary G Flores On 10/31/2024 at 12:12 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 - SIERRA ROSE RESIDENCE
FACILITY NUMBER: 198603754

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2024

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 in 2 out of 3 bathrooms water temperatures test as follow bathroom #2 at 129.0 degrees F., bathroom #3 at 130.0 degrees F., which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2024
Plan of Correction
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Administrator will adjusted water temperature during the visit. Administrator will certify in writing that will ensure water temperature is maintain within the required 105-120 degrees at all times to the department by POC due date 11/2/24.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2024


LIC809 (FAS) - (06/04)
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