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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609009
Report Date: 02/20/2025
Date Signed: 02/20/2025 01:54:21 PM

Document Has Been Signed on 02/20/2025 01:54 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:
02/20/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Yvette Cosme-AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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In conjunction with complaint control # 31-AS-20240716123550, Licensing Program Analyst (LPA) Michael Cava conducted a Case Management (CM) visit to address an incident regarding elements of care and supervision. it was reported that the facility didn't have a required staff, or nurse, on shift, on 06/08/24 and 06/14/24. According to the facility's program design, "an LVN shall remain on duty until relieved by incoming staff". Report received by another government agency reveal that on 06/08/24, Staff 1 (S1), called off, and Staff 2 (S2) was called to provide coverage. However, S2 left at approximately 9pm, which entails that the facility failed to follow their contingency plan, identified the facility's Program Design. Based on this information received, the facility failed to provide services and coverage on 06/08/24 and 06/14/24, to address the needs of the residents in care. This incident was addressed on the above mentioned control number. Citation will be issued on the 809D, and cleared to reflect this CM visit. No further corrections required at this time. Administrator advised, and a copy of this report issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
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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Document Has Been Signed on 02/20/2025 01:54 PM - It Cannot Be Edited


Created By: Michael Cava On 02/20/2025 at 12:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELWYN CALIFORNIA - YARMOUTH
FACILITY NUMBER: 197609009

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/20/2025
Section Cited
CCR
80078(a)

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Responsibility for Providing Care and Supervision: The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by the lack of the facility to adhere to their program description and the resident's admission agreement. According
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No further corrections required at this time. The facility was issued Corrective Action Plan (CAP) from the Regional Center to be completed by 08/15/24, and the licensee submitted their copies of their CAP & POC on 08/24/24
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to both, "an LVN remains on duty until relieved by incoming staff". it was reported that the facility didn't have a required nurse on shift, on 06/08/24 and 06/14/24. This posed an immediate health and safety risk to the resident in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Eva Miller
LICENSING EVALUATOR NAME:Michael Cava
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


LIC809 (FAS) - (06/04)
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