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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005442
Report Date: 06/07/2022
Date Signed: 06/07/2022 03:20:14 PM

Document Has Been Signed on 06/07/2022 03:20 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: 4DATE:
06/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Davishah Taylor, Daniela TillesTIME COMPLETED:
03:35 PM
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This unannounced case management inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following up on a self-reported incident report received in the Orange County Regional Office on 06/02/22 regarding Resident #1 (R1). LPA met with facility staff Davishah Taylor and discussed the purpose of the inspection. Administrator (AD) Daniela Tilles appeared via telephone.

The incident report stated that on 05/24/22 it was reported to the facility that a day program staff who was at the facility working with other residents recorded a video of R1 (who is not a participant in the day program). AD followed up with the day program's director who investigated the situation.

During the inspection, LPA inspected the facility, conducted health and safety checks on residents, interviewed AD, staff, and residents, and requested and reviewed copies of the resident roster and staff roster. AD and facility staff confirmed that it was the staff of the day program who took the video of R1 while working with 2 other facility residents that are participants in the program. AD spoke with the day program's director who addressed the situation with the day program staff who took the video. AD also notified R1's responsible party. AD stated that AD will report any similar incidents to LPA and take additional steps as necessary to protect the personal rights of residents.

There were no health and safety concerns observed in the areas inspected. Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2022
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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