198602387-4-7-2023-28-AS-KRAZ-CQNRVT-20230407132203

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602387
Report Date: 04/07/2023
Date Signed: 04/07/2023 01:22:18 PM

Document Has Been Signed on 04/07/2023 01:22 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	EASTER SEALS SOUTHERN CALIFORNIA ORANGE GROVE		FACILITY NUMBER:	198602387
ADMINISTRATOR:	CHINAKA, LOVEDAY		FACILITY TYPE:	735
ADDRESS:	1657 E ORANGE GROVE BLVD		TELEPHONE:	(818) 512-2494
CITY:	PASADENA	STATE: CA	ZIP CODE:	91104
CAPACITY: 4		CENSUS: 3	DATE:	04/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:51 AM
MET WITH:	Administrator Kirsten Pouri		TIME COMPLETED:	01:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 04/07/2023 at 08:30 am. LPA was met by Staff S1 and explained the purpose of the visit. Administrator Kirsten Pouri later arrived to assist in tour. Facility is licensed to clients 18 to 59 years old. There are three (3) level 4I developmentally disabled clients residing at this facility. Residents at this facility are receiving services from Frank D Lanterman Regional Center. LPA requested and obtained a copy of Personnel Report (LIC 500), and Resident Roster (LIC 9020).

LPA OBSERVATIONS: Tour began at 08:45 am and was led by LPA due to staff assisting clients. The Facility is a single-story dwelling located on a residential street. The facility consists of four (4) client bedrooms, two (2) shared bathrooms, living room, kitchen, dining room, front yard, backyard, and two (2) detached car garage.

· Front Yard: Was clean and well maintained. No hazards were observed.

· Kitchen: LPA observed kitchen area to be clean and appliances appeared to be in working order. LPA observed sufficient 2 days of perishables and 7-day supply on non-perishables. Kitchen sink water temperature was measured at 114.6 degrees F.

· Dining Room/Living room: Dining room was observed to be clean and contained one table and 6 chairs. Living room was observed to contain plenty of seating, and plenty of lighting. Thermostat located in nearby living room hallway read 74 degrees F.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023

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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Document Has Been Signed on 04/07/2023 01:22 PM - It Cannot Be Edited

Created By: Kimberly Ramirez On 04/07/2023 at 12:00 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: 04/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80072(F)

80072 Personal Rights F) Protective devices including, but not limited to, helmets, elbow guards, and mittens which do not prohibit a client's mobility but rather protect the client from self-injurious behavior are not to be considered restraining devices for the purpose of this regulation. Protective devices may be used if they are approved in advance by the licensing agency as specified below. 1. All requests to use protective devices shall be in writing and include a written order of a physician indicating the need for such devices. The licensing agency shall be authorized to require additional documentation including, but not limited to, the Individual Program Plan (IPP) as specified in Welfare and Institutions Code Section 4646, and the written consent of the authorized representative, in order to evaluate the request. 2. The licensing agency shall have the authority to grant conditional and/or limited approvals to use protective devices. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, LPA observed a black helmet haning in C1's bedroom wall, LPA could find physician written order and/or Individual Program Plan (IPP) indicating a need for protective devices, the licensee did not comply with the section cited above in 1 out of 3 clients, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/21/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator will retrain from using such protective devices until this licensing agency approves request. Licensee will submit request to LPA via email no later than 04/21/23 if protective devices are required for C1. Support letter from Regional Center Coordinator stating no protective devices are required if C1 does not require helmet.

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:

Tony Vasallo

LICENSING EVALUATOR NAME:

Kimberly Ramirez

LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA ORANGE GROVE	FACILITY NUMBER: 198602387
	VISIT DATE: 04/07/2023

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Client Rooms 1 - 4: All contained the required furnishings, linens and were observed to be clean. Client# 2 was not currently occupied during visit. At 9:15 am, LPA observed a black helmet hanging next to a wall near C1’s dresser in C1’s bedroom. After a file review of C1’s confidential file, LPA could not locate any physician’s orders for the use of protective devices or any indication from last Individual Program Plan (IPP) dated 01/2023, that C1 requires protective devices.

· Client Bathrooms# 1-2: Were observed to be clean, contained soap, and paper towels. Signs promoting handwashing were observed. Water temperature in bathrooms were within the required 105 – 120 degrees F. Grab bars observed near toilet and showers.

· Centrally Stored Medications: LPA observed medications cabinet located in kitchen area. LPA reviewed 03 client Medication Administration Records (MAR) and prescribed medications.

LPA observed carbon monoxide in hallways. Smoke detector is hard wired and tested during visit. Last fire drill was conducted on 02/10/23 and last earthquake drill was conducted on 03/06/23. LPA reviewed staff files and client files.

Deficiency is being cited during visit. Exit interview was conducted with Administrator Pouri and a copy of this report and

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023

LIC809 (FAS) - (06/04)

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