197608664-5-4-2022-31-AS-MCAA-CE4NX6-20220504105038

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608664
Report Date: 05/04/2022
Date Signed: 05/04/2022 10:51:36 AM

Document Has Been Signed on 05/04/2022 10:51 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:	ELWYN NC - KELVIN 2		FACILITY NUMBER:	197608664
ADMINISTRATOR:	DAVID COOK		FACILITY TYPE:	735
ADDRESS:	6532 KELVIN AVE		TELEPHONE:	(747) 900-6197
CITY:	WINNETKA	STATE: CA	ZIP CODE:	91306
CAPACITY: 4		CENSUS: 4	DATE:	05/04/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Michael Junaid		TIME COMPLETED:	11:00 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	A Required One (1) year Annual- Infection Control visit was conducted today by Licensing Program Analyst (LPA) Michael Cava. LPA met with the assistant administrator, Michael Junaid and stated the purpose of the visit. LPA observed that all four (4) clients were at the facility during the visit. The tour of the physical plant was conducted at 9:00am and the following were noted: The front/main door is the only entrance being utilized for entry. There is a sign on the door that everyone entering at the facility must wear a mask and must be screened. The screening area is located near the entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA Cava was screened by staff upon entry. All staff were observed to be wearing a mask. Including the administrator, there were four (4) staff on duty during the morning visit. One (1) staff is a one to one. The facility submitted a Mitigation Plan. Signs to wear a mask and other COVID 19 prevention protocol signs were posted on the walls. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with covers. The facility has a sufficient supply of PPE in the storage room. Resident rooms: LPA toured four (4) client rooms. All four met regulation. LPA observed rooms to have appropriate bedding sheets, pillowcase, mattress pad, and blanket which are in good condition. There is at least one chair, night stand and sufficient lighting for each client. The mattresses and bedsprings were also checked for condition.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

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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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: ELWYN NC - KELVIN 2	FACILITY NUMBER: 197608664
	VISIT DATE: 05/04/2022

NARRATIVE

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Bathrooms: LPA toured resident bathrooms and checked to make sure bathrooms were clean and in good repair. The hot water temperature measured at 110 degrees F. LPA observed appropriate grab bars and non-skid mat in each bathroom. Towels and washcloths are not shared. Residents have sufficient amounts of supplies for personal hygiene items which is provided by the Licensee.

Common Areas: LPA toured all common areas of the facility. LPA observed common areas to be clean and furniture in good repair. The facility maintains a comfortable temperature at 75 degrees F. LPA observed two (2) fire extinguishers. One in the hallway and one in the garage. The last service date was 2/16/2022. The smoke/carbon monoxide detectors are operational. They are battery operated. There are no issues with Fire Clearance. The last fire drill was conducted at the facility on 5/1/2022.

Outside areas: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. There are no bodies of water.

The garage is not attached to the home. Entrance is located outside of the building. It is kept locked inaccessible to clients. The garage is used as storage space for PPE supplies. There is also another refrigerator kept in the garage that stores perishable food supply. Additional storage space in the garage is utilized for emergency food supply and water.

Food Inspection: LPA conducted a food inspection tour. LPA observed there to be sufficient stock of two- perishable and seven-day non-perishables foods. Snacks and beverages are available for clients in the facility when they want. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Cleaning supplies, pesticides or toxins were stored and locked away.

Laundry: Laundry area is located by the kitchen. Detergent was observed inaccessible to the clients.

Pursuant to CA code of Regulations Title 22 or Health and Safety Code. No deficiencies observed during the day's visit. Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

LIC809 (FAS) - (06/04)

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