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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609009
Report Date: 04/26/2022
Date Signed: 04/26/2022 10:40:23 AM

Document Has Been Signed on 04/26/2022 10:40 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 CALIFORNIA - YARMOUTHFACILITY NUMBER:
197609009
ADMINISTRATOR:EDWARD VELARDEFACILITY TYPE:
735
ADDRESS:10512 YARMOUTH AVETELEPHONE:
(818) 488-1753
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 4CENSUS: 4DATE:
04/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Edward Velarde/ AdministratorTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility in order to conduct an infection control/ annual inspection. LPA was greeted by the facility staff and was directed to a side door to enter the facility. The LPA's temperature was taken and COVID-19 questions were asked before the LPA was allowed entry. The visit was conducted with the house manager and the administrator arrived by the end of the visit.

LPA was able to briefly tour the home inside and out. The smoke alarms and carbon monoxide detectors were tested and functioned properly. All residents have their own bed rooms. Residents and staff were observed to be wearing medical masks.

The home is currently following their mitigation plan.

No deficiencies were observed. Exit interview conducted and report issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2022
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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