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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006002
Report Date: 12/15/2021
Date Signed: 12/15/2021 11:28:26 AM

Document Has Been Signed on 12/15/2021 11:28 AM - 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 ADULT DAY SERVICESFACILITY NUMBER:
306006002
ADMINISTRATOR:ROXAS, MERVINFACILITY TYPE:
775
ADDRESS:1570 E 17TH STREETTELEPHONE:
(714) 672-0866
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY: 50CENSUS: 0DATE:
12/15/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Program Directors Mervin Roxas and Evelyn FaroqueeTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Michelle Reed arrived at the facility to commence an announced Prelicensing visit. Upon arrival, LPA met with the designated Program Directors Mervin Roxas and Evelyn Faroquee.

A change of location application to operate an Adult Day Program was received by Community Care Licensing on 4/27/21 for a capacity of 50 nonambulatory clients. The previous address of the facility was 500 W. Central Ave. Suite A in Brea, CA 92821. The facility will be community and site based. A tour of the physical plan was conducted inside and out.

The facility is in a commercial business complex. There are 3 buildings on the premises. The first building is the front entrance, offices and the computer lab. The second building has the activity room, arts and craft room as well as a room for staff training. The third building is the kitchen/dining room as well as a tv room and more offices. The kitchen has refrigerators, microwaves and a stove/oven. There is ample space for clients to store their belongings and lunches.

The facility has hardwired smoke detectors along with fire sprinklers and carbon monoxide sensors throughout each building. Fire extinguishers present in each building and were fully charged. The fire inspection was completed and approved by the Santa Ana Fire Department on 9/30/21. The facility has emergency exit plans posted and will perform monthly emergency drills. Camera's are present throughout the perimeters of the buildings.

LPA inspected the resident restrooms. Grab bars are secure. Soap, toilet paper and paper towels were present. Toxins will be stored in a locked closet. The water temperature was measured at 106 degrees F.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2021
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: EASTERSEALS ADULT DAY SERVICES
FACILITY NUMBER: 306006002
VISIT DATE: 12/15/2021
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There is no food service performed at the facility as client's bring their lunch. The facility will perform medication management as needed. There is a nurse's room in the facility and all medications will be kept locked and inaccessible to clients. First aid kits were present. Staff and client files will be kept locked. Emergency supplies were also present.

The three buildings have ample seating space and supplies. No toxins/sharps will be available to clients. LPA also observed an isolation room for clients who need a quiet space and/or are not feeling well.

The outside patio has a fountain with shade. The doors that lead outside will be alarmed. Delayed egress and secured perimeters are not present nor approved by the fire department.

Component III was completed.

The Prelicensing is complete and there are no deficiencies that require correction. The License will be granted upon a final review by the Central Applications Bureau and approval by management.

An exit interview was conducted with Mervin Roxas and Evelyn Faroquee and a copy of this report was provided.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
LIC809 (FAS) - (06/04)
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