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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005462
Report Date: 12/23/2024
Date Signed: 12/23/2024 12:54:51 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/25/2024 and conducted by Evaluator Dwayne L Mason
COMPLAINT CONTROL NUMBER: 22-AS-20241125115325
FACILITY NAME:EASTERSEALS SOUTHERN CALIFORNIA-CLARISSA RESIDENCEFACILITY NUMBER:
306005462
ADMINISTRATOR:ARMANDO FLORESFACILITY TYPE:
735
ADDRESS:14361 CLARISSA LANETELEPHONE:
(714) 665-8773
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY:4CENSUS: 3DATE:
12/23/2024
UNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Sean Estrella - AdministratorTIME COMPLETED:
01:10 PM
ALLEGATION(S):
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Staff retaining a resident that requires a higher level of care
INVESTIGATION FINDINGS:
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This unannounced investigation inspection by Licensing Program Analyst (LPA) Dwayne Mason Jr. is being conducted to conclude this agency’s investigation in the complaint allegation(s) mentioned above. LPA arrived at the facility and was greeted by facility staff. LPA spoke with Administrator Sean Estrella and explained the nature of the inspection. The department received a complaint on 11/25/2024 alleging staff is retaining a resident that requires a higher level of care. During the investigation, the department interviewed facility Administrator (AD) and staff.

On 12/5/2024 LPA conducted a visit to the facility to initiate investigation into the above allegation. LPA obtained the following documents: resident roster, staff roster, admissions agreement, physician's report, Indiviual Program Plan, Individual Support Plan, Behavior Progress Report, Semi-Annual Review, hospital discharge paperwork and staff schedule for November 2024. On 12/23/2024, LPA returned to the facility and collected the staff schedule for September 2024 and October 2024.
(continued on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 22-AS-20241125115325
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: EASTERSEALS SOUTHERN CALIFORNIA-CLARISSA RESIDENCE
FACILITY NUMBER: 306005462
VISIT DATE: 12/23/2024
NARRATIVE
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On 12/5/2024 and 12/23/2024, LPA conducted interview with Staff and Administrator. Of the 5 staff interviewed, each of them stated a need for supervision of Client 1 (C1) during times when C1 is up ambulating was identified. Per AD and staff, C1's need for supervision was communicated to the Direct Service Providers (DSPs) from Administrator. AD stated that when C1 is up and ambulating they are at risk of falling and sustaining an injury due to their walking gait or due to seizures. AD stated that C1 gets up to ambulate at anytime. AD also stated that C1 may experience seizures at anytime as well. Due to the potential for C1 to ambulate at anytime and experience seizures at anytime, the LPA determined C1 requires monitoring 24 hours a day. Of the 5 staff interviewed, 4 of them stated C1 has a direct 1-on-1 (D1) staff through the Adult Day Program (ADP) that C1 attends. Of the 5 staff interviewed, 3 of them stated C1's ADP D1 works with C1 for 8 hours a day in the morning and afternoon.

Per AD, the facility has 2 DSPs working during night shifts and 2 DSPs working during overnight (NOC) shifts. LPA verified this via the staff schedule for September 2024, October 2024 and November 2024. Based on interviews, C1 requires monitoring 24 hours a day due to behaviors(getting up to ambulate at any time), walking gait and seizures that can occur at anytime. Based on interviews conducted and documents reviewed, the LPA determined the facility identified a need for a higher level of care of for C1, but did not take the necessary steps to fulfill it.

The preponderance of evidence standard has been met. The allegation of staff is retaining a resident that requires a higher level of care is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred. An exit interview was conducted, and this report was reviewed with facility staff. A copy of this LIC-9099, deficiency page and appeal rights were provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20241125115325
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: EASTERSEALS SOUTHERN CALIFORNIA-CLARISSA RESIDENCE
FACILITY NUMBER: 306005462
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/13/2025
Section Cited
CCR
85065(b)
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Personnel Requirements 85065(b)The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs.
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Administrator stated they will either hire/assign staff to solely provide 24 hour direct supervision to C1 during all shift or issue an eviction notice to C1 indicating C1 has a need for a level of care higher than what hte facility can provide. AD stated they will notify LPA upon completion of POC.
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Based on the investigation, the Licensee did not comply with the above regulation due to staff identifying a client's need for 24 hour direct supervision without designating staff members to solely provide direct supervsion of C1 during all shifts.
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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.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3