197609009-5-23-2023-31-AS-MCAA-CS4P92-20230523110625

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609009
Report Date: 05/23/2023
Date Signed: 05/23/2023 11:06:52 AM

Document Has Been Signed on 05/23/2023 11:06 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 - YARMOUTH		FACILITY NUMBER:	197609009
ADMINISTRATOR:	TAYO LABEODAN		FACILITY TYPE:	735
ADDRESS:	10512 YARMOUTH AVE		TELEPHONE:	(818) 488-1753
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY: 4		CENSUS: 3	DATE:	05/23/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:38 AM
MET WITH:	Tayo Labeodan		TIME COMPLETED:	11:15 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	Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with the administrator, Tayo Labeodan and explained the reason for the visit. At approximately 8:45am, with the assistance of the administrator, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms and carbon monoxide detectors are dual. It is hardwired and interconnected. The fire extinguisher is located between resident rooms #3 and #4. The charge date is 05/22/2022. The facility conducted two emergency drills this month. One on 05/06/23 and the other on 05/20/23. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Bedrooms: There were four (4) bedrooms designated for residents' use. Three of the bedrooms, in use by residents were were properly furnished with appropriate beddings and linens with sufficient lighting. The other three bedroom is currently not in use at this time, but was also observed properly furnished with appropriate beddings, linens and sufficient lighting. Bathrooms: There are three (3) bathrooms designated for residents' use. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 111.2 degrees Fahrenheit. No cleaning supplies were observed accessible to clients in the bathrooms. Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

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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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 CALIFORNIA - YARMOUTH	FACILITY NUMBER: 197609009
	VISIT DATE: 05/23/2023

NARRATIVE

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Surrounding Grounds: Entry/exits were free of hazard and obstructions. Passageways in the front and backyard were clear. The laundry area is located by the kitchen. Cleaning supplies and detergents were observed locked in the laundry area.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records were review for proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC809 (FAS) - (06/04)

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