197608218-2-23-2024-31-AS-MCAA-D2QR9Q-20240223114956

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608218
Report Date: 02/23/2024
Date Signed: 02/23/2024 11:50:00 AM

Document Has Been Signed on 02/23/2024 11:50 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, 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: 5	DATE:	02/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:01 AM
MET WITH:	Jenneth Aguilar		TIME COMPLETED:	11:50 AM

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 9:15am, with the assistance of the administrator, LPA took a tour of the physical plant. Required postings were observed throughout the walls of the facility, in and outside of th home. The smoke alarms are battery operated and interconnected. The carbon monoxide detector is located by the living room/dining room area, plugged into the wall. It functions properly. The fire extinguisher is located in the kitchen. It was purchased on March 23, 2023. Administrator aware, and will be purchasing a new one. 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. Six (6) are designated for residents' use. One room is for staff use. All rooms, occupied by the residents are private. All rooms were observed to be properly furnished with appropriate beddings and linens with sufficient lighting. Exits and passageways were clear of obstruction during the visit. Bathrooms: There are three (3) bathrooms. Two (2) bedrooms are designated for residents' use, and one is for staff. Bathrooms, designated for resident's use were properly supplied and had functional fixtures. Hot water temperature was measured at 115 degrees Fahrenheit. No cleaning supplies were observed in any of the resident bathrooms the bathrooms. All cleaning supplies are kept in a locked storage, outside of the home. 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: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

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: 02/23/2024

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. The backyard is large enough to hold outdoor activities when the weather permits. There is a swimming pool in the backyard, that has a five foot wall surrounding the parameters. There is a gate, that is also at least five foot high, with a combination/coded lock required to enter in order for access and to prevent residents from gaining entry. There is also a guest house/ADU, in the back, designated for staff use. Guest house is not accessible to the residents. 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 a medication cart, located in the kitchen. It is observed 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: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

LIC809 (FAS) - (06/04)

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