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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602387
Report Date: 04/15/2022
Date Signed: 04/15/2022 05:03:41 PM

Document Has Been Signed on 04/15/2022 05:03 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:EASTER SEALS SOUTHERN CALIFORNIA ORANGE GROVEFACILITY NUMBER:
198602387
ADMINISTRATOR:CHINAKA, LOVEDAYFACILITY TYPE:
735
ADDRESS:1657 E ORANGE GROVE BLVDTELEPHONE:
(818) 512-2494
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 4CENSUS: 4DATE:
04/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:41 PM
MET WITH:Kriten Pouri AdminitratorTIME COMPLETED:
05:13 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lopez and Bennette Pena conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPAs met with LVN Ernesto Aductante and Administrator Kristen Pouri arrive a short later and LPAs explained the purpose of the visit. Home is Level 4 Home.The home has 1 ambulatory clients and 3 non ambulatory, The facility also has one (1) client who has a restricted health condition (G-Tube) and the restricted health condition plan is on file but not signed by reginal. 2 clients are between the ages of 18-59 and 2 are over 59 years of age. Facility has applied for age waiver for 2 clients back in 2019 but does not have waiver on hand. Facility is a one story home located in a residential area consisting of 4 private rooms, 2 bathrooms, living room, family room, kitchen, dining room, backyard patio area, and detached garage. The last fire drill was completed on April 12, 2022. Administrator certificate expires 11/25/22

The following were observed/inspected:
· COVID-19 signs are posted at the entrance. Visitors are screened in the main entrance and a log is kept.
· Infection control signs and other COVID-19 signs are posted throughout the facility in the bathrooms, kitchen, and hallway to promote handwashing, cough/sneeze etiquette, and physical distancing.
· Facility has one designated isolation room.
· Three (4) client rooms, common areas, bathrooms, and outdoor physical plant was inspected.
· All client rooms were not equipped with alcohol-based hand sanitizer but available throughout the facility
· Four (4) centrally stored client medication records were reviewed.
· Staff responsible for direct care and supervision were observed wearing masks.
· Clients were not observed wearing masks but adhering to public health social distance guidelines.
· Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
· A posted Emergency Disaster Plan was observed.
· PPE's were observed.
· Staff and resident files were not reviewed during today's visit.
Deficiencies where cited. (see 809D)
Exit interview was conducted with Assistant Administrator Kristen Pouri. A copy of the report was provided.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2022
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 04/15/2022 05:03 PM - It Cannot Be Edited


Created By: Alberto Lopez On 04/15/2022 at 04:52 PM
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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA ORANGE GROVE
FACILITY NUMBER: 198602387

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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80024(a)(b) TYPE B Exceptions and Waivers-LPA observed C1 and C2 to be over the age of 59 without an age exception which pose health and safety to clients.
POC Due Date: 04/22/2022
Plan of Correction
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Licensee shall relocate clients to an elderly facility or apply for an age exception by due date.
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:Christine Yee
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2022


LIC809 (FAS) - (06/04)
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