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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608664
Report Date: 08/27/2024
Date Signed: 08/27/2024 02:03:52 PM

Document Has Been Signed on 08/27/2024 02:03 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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ELWYN NC - KELVIN 2FACILITY NUMBER:
197608664
ADMINISTRATOR/
DIRECTOR:		AUGUSTINE ONUMAJURUFACILITY TYPE:
735
ADDRESS:6532 KELVIN AVETELEPHONE:
(747) 900-6197
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY: 4CENSUS: 4DATE:
08/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Michael Junaid, LVNTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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At 12:15pm Licensing Program Analysts (LPAs), Angela Panushkina and Huma Rahimi, conducted an unannounced annual inspection at the facility mentioned above. LPAs met with the Designee, and explained the reason for the visit. Physical tour was conducted with the Designee and LPAs observed the following:

Kitchen: At approximately, 12:20pm LPAs toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps observed to be locked in the kitchen drawer

Medications: At approximately, 12:25pm LPAs observed medications are centrally stored and locked in a hallway closet.

Bedrooms: Facility has four (4) bedrooms designated for clients use. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Facility has awake staff.

Bathrooms: LPAs observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPAs observed appropriate grab bar and client's bathroom had non-skid mat. LPAs observed appropriate hand washing signs posted in each bathroom. Hot water temperature measured at 117.3°F.



Common Areas: The facility maintains a comfortable temperature at 72°F. The living room and dining area appeared clean and were properly furnished. The living room has a television, comfortable furniture. No obstructions and or tripping hazards throughout the facility. Laundry is located by the room #4 at the end of the hallway. LPAs observed all detergents locked and inaccessible to clients in care. Detached garage is kept Continue on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2024
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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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: 08/27/2024
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locked and being used for extra storage and emergency supply.

Outside areas: At approximately, 12:40pm LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients.



Smoke detectors/carbon monoxide. Smoke detectors were located throughout the facility, and at 1:30pm they were tested and observed to be operational. Carbon monoxide was located in a hallway and was also tested and observed to be operational.


Between 1:40pm to 2:20pm, LPAs reviewed records of four (4) clients and two (2) staff. Client and staff records appeared to be complete and updated.

Administrative: LPA collected Certificate of Liability Insurance, and LIC500.

No deficiency cited during todays visit.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC809 (FAS) - (06/04)
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