197608218-4-2-2025-31-AS-MCAA-DFCTPQ-20250402145443

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608218
Report Date: 04/02/2025
Date Signed: 04/02/2025 02:55:47 PM

Document Has Been Signed on 04/02/2025 02:55 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/ DIRECTOR:	JENNETH AGUILAR		FACILITY TYPE:	740
ADDRESS:	11436 OSTORM AVENUE		TELEPHONE:	(818) 620-2202
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	04/02/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:49 AM
MET WITH:	Jenneth Aguilar		TIME VISIT/ INSPECTION COMPLETED:	03:00 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 12:00pm, with the assistance of the administrator, LPA took a tour of the physical plant. The facility is a one story building. Required postings were observed posted on the walls. The smoke alarms are battery operated and interconnected. The carbon monoxide detector is located by the living room/dining room area. The fire extinguisher is located in the kitchen. It was purchased on 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. 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.

Eva Miller	TELEPHONE: (818) 596-4373
Michael Cava	TELEPHONE: (818) 389-7921
	DATE: 04/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 04/02/2025

NARRATIVE

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Common Areas: These included the living room and dining area. The living room is equipped with a couch, recliner, tables, and television. The fireplace is non-functional. The dining room table is large enough to seat up to six (6) residents. Furniture were observed to be maintained and in good repair. Floors were mopped and clean. Passageways were clear. The auditory alarms on all exit doors were on and functional at the time of the visit.

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. 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.

Laundry: The laundry area is located by the kitchen. No detergents or cleaning supples observed during the day's inspection.

Garage: Garage is attached to the home. Entry is through the side. Garage is locked and used for storage.

Staff Work Station: Staff workstation is located by the corner of the living room, where staff and resident records are locked and maintained.

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 compliance and training is up to date.

Medications: Medications are centrally stored in a locked medication cart, located in the kitchen. Medications were reviewed for proper storage and documentation.

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: 04/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025

LIC809 (FAS) - (06/04)

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