197608218-4-29-2023-31-AS-MCAA-CRCSJ2-20230429135425

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608218
Report Date: 04/29/2023
Date Signed: 04/29/2023 01:54:35 PM

Document Has Been Signed on 04/29/2023 01:54 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ELYSIUM RESIDENTIAL CARE		FACILITY NUMBER:	197608218
ADMINISTRATOR:	JENNETH AGUILAR		FACILITY TYPE:	740
ADDRESS:	11436 OSTORM AVENUE		TELEPHONE:	(818) 620-2202
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	6	CENSUS: 6	DATE:	04/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:47 AM
MET WITH:	Jenneth Aguilar		TIME COMPLETED:	02:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with the administrator, Jenneth Aguilar and explained the reason for the visit. At approximately 9:00am, with the assistance of the administrator, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are battery operated and interconnected. The carbon monoxide detector is located by the living room/dining room area. It functions properly. The fire extinguisher is located in the kitchen. It is new. Purchase date is March 23, 2023. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives are stored in a locked drawer. Properly labeled medications were locked in one of the kitchen cabinets. Bedrooms: There were seven (7) bedrooms designated for residents' use. All rooms are private. All reooms were observed to be properly furnished with appropriate beddings and linens with sufficient lighting. Exits and passageways were clear of obstruction during the visit. In addition, LPA interviewed four residents. These residents were satisfied with care and supervision provided. No concerns were expressed. Bathrooms: There are three (3) bathrooms designated for residents' use. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 111 degrees Fahrenheit. No cleaning supplies were observed in the bathrooms. Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELYSIUM RESIDENTIAL CARE	FACILITY NUMBER: 197608218
	VISIT DATE: 04/29/2023

NARRATIVE

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Surrounding Grounds: Entry/exits were free of obstruction. The backyard has a gazebo and there were furniture appropriate for outdoor use. There is a swimming pool in the backyard, that has a fight foot wall surrounding the parameters. There is a gate, that is also at east five foot high, with a combination/coded lock required to enter in order for access and to prevent residents from gaining entry. The outdoor area was free of hazards. The laundry area is located by the kitchen.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records were reviewed for proper documentation. Medications are centrally stored in the kitchen, locked and inaccessible to residents in care.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2023

LIC809 (FAS) - (06/04)

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