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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608613
Report Date: 04/10/2024
Date Signed: 04/10/2024 11:05:40 AM


Document Has Been Signed on 04/10/2024 11:05 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:ELWYN NC - MAYALLFACILITY NUMBER:
197608613
ADMINISTRATOR:STEVI TAYLORFACILITY TYPE:
735
ADDRESS:19638 MAYALL STTELEPHONE:
(747) 202-0471
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY:4CENSUS: 4DATE:
04/10/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:24 AM
MET WITH:TAYO LABEODAN- Administrator TIME COMPLETED:
11:15 AM
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 Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced Case Management visit to the facility. The purpose of today’s visit was to serve the Order of Immediate Exclusion from Facility for Staff #2 (S2)

On today's visit LPA met with Administrator, Tayo Labeodan and explained the reason for the visit. Administrator was served an Immediate Exclusion Order for Staff #2 (S2). The administrator received permission for all immediate exclusion letters for all facilities that S2 was working at to be given to him as well at the Elwyn CA - Mayall home. The facilities were: Elwyn NC -Kelvin 2, Elwyn California - Yarmouth, Elwyn California - Index, and Elwyn NC - Kelvin 1.

No immediate Health and Safety Hazard was noted during this visit.


Exit interview held. A copy of the report was provided to the Administrator.

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024
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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