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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608664
Report Date: 12/29/2023
Date Signed: 12/29/2023 12:00:51 PM

Document Has Been Signed on 12/29/2023 12:00 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ELWYN NC - KELVIN 2FACILITY NUMBER:
197608664
ADMINISTRATOR:AUGUSTINE ONUMAJURUFACILITY TYPE:
735
ADDRESS:6532 KELVIN AVETELEPHONE:
(747) 900-6197
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY: 4CENSUS: 4DATE:
12/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Frances TullaoTIME COMPLETED:
12:00 PM
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At 8:20 a.m. on 12/29/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and disclosed the reason for the visit. LPA and staff toured the facility inside and out at 8:30 a.m. The Administrator was unable to attend the visit but notified staff at approximately 10:45 a.m. that they could sign today's report in their absence.

The facility was last visited on 02/21/2023 for a complaint visit. It is a single story building with four (04) bedrooms, three (03) bathrooms, kitchen. garage, common areas, and outdoor areas. It has an approved fire clearance for four (04) bedridden clients.

At the main entrance, LPA observed a maintained front yard with secure perimeter fencing. Postings observed inside included the facility license, house rules, confidential complaint contacts, COVID precautions, personal rights, emergency disaster plan, staff schedule, and the facility sketch. A screening station with a visitor log, digital thermometer, masks, and gloves was located near the main entrance.

The facility has four (04) bedrooms. All bedrooms contained a chair, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition.

Walls, floors, windows, screens, and blinds were clean and in good repair. At 8:50 a.m. LPA measured the room temperature to be 74 degrees Fahrenheit. Activities, television, and board games were observed in the living room. An office and medication room were located near the front. Confidential files and medications were locked in the office and medications room.

The facility has three (03) bathrooms. All bathrooms contained liquid soap, paper towels, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. LPA also observed a commode and shower seat in the shared bathroom. At approximately 9:00 a.m. LPA measured the water temperature in the shared bathroom to be 108.5 degrees Fahrenheit.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ELWYN NC - KELVIN 2
FACILITY NUMBER: 197608664
VISIT DATE: 12/29/2023
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LPA observed an adequate supply of perishable and non-perishable foods in the refrigerator, freezer, and pantry. The stove hood was clean. Appliances were in good condition. Sharps were locked below the counter top. Cleaning solutions were locked below the sink.

A washing machine and dryer were located near the hallway. Both were in working order. Detergents were locked in a closet nearby.

LPA observed a covered patio area in the rear of the facility. The patio contained furniture in good condition and gardened areas. The garage was locked and contained additional incontinence and paper supplies, old files, extra food, and another freezer.

All emergency exit paths were free from obstructions. Four (04) out of four (04) exit doors in bedrooms were unlocked Three (03) out of three (03) exit gates were unlocked with self-closing latches. Evacuation routes were posted and labelled on the facility sketch. Six (06) out of six (06) auditory alarms were turned on and functioning. At approximately 9:10 a.m. the smoke and carbon monoxide detectors were tested and operational. LPA observed overhead fire sprinklers throughout the facility. At approximately 9:15 a.m. LPA observed three (03) fully charged fire extinguishers in the kitchen, hallway, and garage. They was last inspected on 02/14/2023. The house telephone was deemed operational at 9:20 a.m. Surveillance cameras are used on the exterior and in common areas.

LPA conducted a record review of staff and client files at 10:30 a.m.

No immediate health and safety hazards were observed during today’s visit.

During today's inspection, the facility was in compliance with Title 22 regulations.

Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023
LIC809 (FAS) - (06/04)
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