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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609009
Report Date: 05/23/2024
Date Signed: 05/23/2024 02:24:22 PM

Document Has Been Signed on 05/23/2024 02:24 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 CALIFORNIA - YARMOUTHFACILITY NUMBER:
197609009
ADMINISTRATOR/
DIRECTOR:
TAYO LABEODANFACILITY TYPE:
735
ADDRESS:10512 YARMOUTH AVETELEPHONE:
(818) 488-1753
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 4CENSUS: 4DATE:
05/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Yvette CosmeTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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In conjunction with complaint control #31-AS-20240521151323, Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with the administrator, Yvete Cosme, and explained the reason for the visit.

At approximately 9:15am, with the assistance of the administrator, LPA took a tour of the physical plant. The facility is level 4. The building is one story Required postings were observed in the entry area. The smoke alarms and carbon monoxide detectors are dual and interconnected. There are two fire extinguishers. One is located in the kitchen, and the other is located by resident room #3. The charge date is April 5, 2024.

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 & cleaning supplies are stored locked in the laundry area, which is adjacent to the kitchen.

Bedrooms: There are four (4) bedrooms designated for residents' use. All four bedrooms are private. Bedrooms were observed to be properly furnished with appropriate beddings and linens with 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 between 114 and 120 degrees Fahrenheit. No cleaning supplies were observed in any of the bathrooms during the day of the inspection.

Common Areas: These included the living room and dining area. The living room was furnished two couches, a table and television. The dining room table is large enough to seat up to four (4) individuals.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2024
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 CALIFORNIA - YARMOUTH
FACILITY NUMBER: 197609009
VISIT DATE: 05/23/2024
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Living room and dining room furniture where in good repair. Floors were mopped and clean. Exits and passageways were clear. Auditory alerts at all exits were tested and are all functional.

Surrounding Grounds: Entry/exits to the front and back yards were free of obstruction. There is a patio area where activities can be held. There are furniture, appropriate for outside use. The side gate was checked to insure that there is no exterior lock and is clear to exit/evacuate in case of an emergency.

Laundry area: The laundry area is located adjacent to the kitchen. Laundry was observed being done by staff. Cleaning supplies and detergents are stored and locked in a cabinet within the laundry area.

Staff Workstation/Office: There is a staff office located by the front entrance, where the medication cart, staff and resident records are kept and maintained. The medication was observed locked, and records were kept in a filing cabinet

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: Medications are kept locked in a medication cart in staff office. Medication and Medication Records were reviewed for proper storage and documentation.

Garage: The garage is attached to the building. It is used for storage of extra perishable and non-perishable food, emergency water supply, incontinent supplies, PPE and cleaning supplies. Entry to the garage is at the side, which is kept locked and only accessible to staff.

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 this report issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024
LIC809 (FAS) - (06/04)
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