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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005462
Report Date: 02/20/2025
Date Signed: 02/20/2025 12:34:20 PM

Document Has Been Signed on 02/20/2025 12:34 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-CLARISSA RESIDENCEFACILITY NUMBER:
306005462
ADMINISTRATOR/
DIRECTOR:		ARMANDO FLORESFACILITY TYPE:
735
ADDRESS:14361 CLARISSA LANETELEPHONE:
(714) 665-8773
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 4CENSUS: 2DATE:
02/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:54 AM
MET WITH:Sean Estrella- Administrator TIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry by Caregiver Chris A. and explained the reason for the visit. Administrator Sean Estrella arrived at the facility at 9:30 am.

At 8:00am LPA Mendivil reviewed 2 out of 2 client files and 8 out 8 staff files and all contained the required documentation. LPA Mendivil toured the facility with Caregiver Sefan around 9:00am. The facility is a one-story home with five bedrooms, three bathrooms, kitchen, dining room, living room, family room, backyard and attached 2-car garage. Facility appears clean, safe and sanitary. LPA Mendivil observed the water temperatures read as follows: kitchen 106.7 degrees, resident bathroom 95.5 degrees,resident bathroom #2 66.4 degrees and staff bathroom 99.9 degrees. LPA Mendivil observed all clients rooms had required elements, including bed, chair, closet space and ample lighting. Facility had extra linens for clients in the hallway closet. LPA observed medication for each client is kept locked in a cabinet near the kitchen. LPA observed backyard has two shaded sitting/lounging areas. Exit gates are unlocked and self latching. LPA observed exit gates to be unobstructed.LPA Mendivil observed smoke detectors and carbon monoxide detectors to be operational. LPA Mendivil observed emergency food and water stored in the garage. LPA observed facility has the required 2 day supply of perishables and 7 day suppy of non perishables. LPA Mendivil observed board games, exercise equipment, a Ms. Pacman Arcade game, Jukebox and more for client use.

Based on observations made deficiencies are being cited per California Code of Regulations Title 22. An exit interview was conducted and a copy of this report was provided along with appeal rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 02/20/2025 12:34 PM - It Cannot Be Edited


Created By: Andrea Mendivil On 02/20/2025 at 11:03 AM
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
, 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: 02/20/2025

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 3 out of 4 sinks. The resident's and staff bathrooms read as the following: 95.5 , 66.4 and 99.9 degrees which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/21/2025
Plan of Correction
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Administrator agreed to adjust water heater to reach the minimum temperature of 105 degrees. Administrator to provide proof that temperature has adjusted to LPA by POC due date. Administrator agreed if temperature does not meet temp requirements after adjustment then sinks/water heater will be maintenanced. Administrator to use kitchen sink for all hand washing needs until temperature is adjusted.
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:Alisa Ortiz
LICENSING EVALUATOR NAME:Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


LIC809 (FAS) - (06/04)
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