197608661-4-7-2022-29-AS-ECAS-CD9UU7-20220407155304

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608661
Report Date: 04/07/2022
Date Signed: 04/07/2022 03:54:33 PM

Document Has Been Signed on 04/07/2022 03:54 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ELWYN NC - KELVIN 1		FACILITY NUMBER:	197608661
ADMINISTRATOR:	JAIMIE LYNN SMITH		FACILITY TYPE:	735
ADDRESS:	5651 KELVIN AVE		TELEPHONE:	(747) 900-6742
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY: 4		CENSUS: 4	DATE:	04/07/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Crystal Cortes		TIME COMPLETED:	04:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a required annual visit at 9:06 am. This annual had a specific emphasis on infection control practices and procedures. The LPA met with staff Crystal Cortes, Keandre Lee and Femi Adeniyi and explained the reason for the visit.

The Administrator was unavailable during visit however LPA Campos spoke with Administrator Brandy Maynard at 3:15 p.m. to discuss Infection control procedures.

Administrator provided authorization for staff Femi Adeniyi to sign the report.

The LPA, with the guidance of staff, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

BEDROOMS: There are (4) four bedrooms designated for resident use. All bedrooms have a direct exit to the exterior. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. During the visit, the LPA observed signage in all of the bathrooms pertaining to proper hand hygiene. All cleaning supplies were inaccessible to residents in care. Between 1:33 p.m. – 1:53 p.m., the LPA measured the hot water temperature in 1 ½ baths. The hot water temperatures measured 112.1 and 126.8 degrees Fahrenheit.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be properly stored and locked at time of visit. Hot water measured at 123.9 degrees Fahrenheit at 1:53 a.m.

Continued on LIC 809-C

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022

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 04/07/2022 03:54 PM - It Cannot Be Edited

Created By: Elsie Campos On 04/07/2022 at 03:37 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELWYN NC - KELVIN 1	FACILITY NUMBER: 197608661
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as the hot water registered above 120 degrees farenheit, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 04/15/2022
	Plan of Correction
1 2 3 4	The adminsitrator agreed to do the following: 1. Adjust the water heater. Staff adjusted during today's visit. 2. Complete a 5 day log of hot water temperature. Submit to CCL no later than 4/15/22.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Jeralyn Ann Pfannenstiel

LICENSING EVALUATOR NAME:

Elsie Campos

LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELWYN NC - KELVIN 1	FACILITY NUMBER: 197608661
	VISIT DATE: 04/07/2022

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COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. A covered fireplace was observed in the living room. Security cameras were observed around the outside perimeter of the facility. The facility maintained a temperature of 68 degrees. All exits have functioning auditory devices and activated during the visit. The LPA observed the required postings in the common area and reminded the administrator and staff to ensure most recent Provider Information Notices (PIN)’s regarding visitation are visibly posted. At 1:45 pm the LPA observed the hallway closet unlocked and accessible to residents in care, containing resident hygiene supplies and ointments.

BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. No bodies of water were noted. The LPA observed a locked shed containing decorations and gardening supplies.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator Brandy Maynard regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient, and facility has sufficient disinfectants. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time and the LPA reviewed facility’s policies and procedures as it pertains to infection control.

Exit interview conducted. A copy of the report and appeal rights were provided via email.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided via email.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022

LIC809 (FAS) - (06/04)

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