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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005442
Report Date: 09/28/2021
Date Signed: 09/28/2021 12:49:16 PM

Document Has Been Signed on 09/28/2021 12:49 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:EASTERSEALS SOUTHERN CALIFORNIA - COUNTRY HILLSFACILITY NUMBER:
306005442
ADMINISTRATOR:ARMANDO FLORESFACILITY TYPE:
735
ADDRESS:640 WEST COUNTRY HILLS DRIVETELEPHONE:
(714) 526-4079
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY: 4CENSUS: 1DATE:
09/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Whitley John TIME COMPLETED:
12:50 PM
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Norman Woodridge for the purpose of conducting an Annual Inspection. LPA met with Administrator (AD) Whittley John and discussed the purpose of the inspection. During the inspection, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, garage, and kitchen.

LPA observed the following:

There were 1 staff and 1 client present with the remaining clients attending day care programs. LPA confirmed present client was doing well. Client rooms were clean and organized. LPA observed a 2-day supply of perishables and a 7-day supply of non-perishables. LPA observed hallways and walkways that were free of obstruction. LPA reviewed client and staff files, as well as the client and staff roster.

No deficiencies were noted during the inspection.

An exit interview was conducted with AD and a copy of this report was provided.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Norman Woodridge
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2021
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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