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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608661
Report Date: 05/04/2023
Date Signed: 05/04/2023 03:43:43 PM

Document Has Been Signed on 05/04/2023 03:43 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 1FACILITY NUMBER:
197608661
ADMINISTRATOR:BRANDY C MAYNARDFACILITY TYPE:
735
ADDRESS:5651 KELVIN AVETELEPHONE:
(747) 900-6742
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 4CENSUS: 4DATE:
05/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:44 AM
MET WITH:Crystal CortesTIME COMPLETED:
03:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angel Ascencio arrived at the facility unannounced to conduct a required annual visit at 9:44 a.m. The LPA met with staff Crystal Cortes and explained the reason for the visit. The Administrator was unavailable during visit. Administrator Maynard provided authorization for staff Crystal Cortes to sign the report.

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

BEDROOMS: All client rooms are set up with beds, night stands, lamps, chests of drawers,


chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean
linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a
bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for
easy passage between the beds. In addition, no bedroom was used as a passageway to another
room, bath or toilet. There are four (4) total bedrooms for client use – all client rooms are
private rooms.

RESTROOMS: There are two (2) total bathrooms at the home. One (1) is designated as a staff
bathroom and one (1) is in the common hallway. The clients bathroom has a shower with non-skid materials. The toilet and shower have grab bars. During the visit, the LPA observed signs in all of the bathrooms pertaining to proper hand hygiene. All cleaning supplies were inaccessible to client in care. The hot water temperatures measured 115.9 degrees Fahrenheit.

KITCHEN: Kitchen knives are stored in a locked closet by the kitchen. The supply of dishes, utensils, pots, pans and drink ware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. Continued on LIC 809 - C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2023
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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Document Has Been Signed on 05/04/2023 03:43 PM - It Cannot Be Edited


Created By: Angel Ascencio On 05/04/2023 at 01:39 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: 05/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85068.2(b)(1)(C)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as 1 out of 6 clients did not have their LIC 602, Physicians Report which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2023
Plan of Correction
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Administrator will obtain completed copy of the LIC 602 Physicians Report. Administrator will send copies to LPA by 05/10/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kristin Heffernan
LICENSING EVALUATOR NAME:Angel Ascencio
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/04/2023 03:43 PM - It Cannot Be Edited


Created By: Angel Ascencio On 05/04/2023 at 01:39 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: 05/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as 2 out of 4 clients did not have their tuberculosis results which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2023
Plan of Correction
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Administrator will have clients tested for Tuberculosis. Administrator will submit documentation to LPA by 05/19/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kristin Heffernan
LICENSING EVALUATOR NAME:Angel Ascencio
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023


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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: 05/04/2023
NARRATIVE
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The supply of perishable and nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Kitchen, laundry and house cleaning supplies are stored in a locked cabinet. No flies or other vermin were observed. Hot water was measured at 116.7 degrees Fahrenheit.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and


good condition. At the time of the visit, common seating area and dining room furniture was
observed to be in good condition. Chairs were observed to be at least 6 (six) feet apart for social
distancing. The LPA observed the required postings in the common hallway. Fire extinguishers
were observed to be serviced within the last year. The facility smoke alarm system is hardwired and
operated normally at the time of visit. Medications were observed to be locked in a closet by the
kitchen and contained at least 30 days of worth of medication. Laundry room contained a locked cabinet for laundry supplies. The backyard has a covered outdoor area equipped with furniture for client use. There
were no bodies of water noted.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Staff 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. 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.

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.

At 11:00 a.m., during resident file review, C1's did not have an LIC 602, Physician's Report.
At 11:30 a.m., during resident file review, C2 and C3 did not have documented Tuberculosis Test.

Exit interview conducted. A copy of the report and appeal rights were issued.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023
LIC809 (FAS) - (06/04)
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