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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609010
Report Date: 10/24/2022
Date Signed: 10/24/2022 11:35:17 AM

Document Has Been Signed on 10/24/2022 11:35 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 - INDEXFACILITY NUMBER:
197609010
ADMINISTRATOR:TAYO LABEODANFACILITY TYPE:
735
ADDRESS:17328 INDEX STTELEPHONE:
(626) 500-1430
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 4CENSUS: 4DATE:
10/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Gerlie Miguel/ Licensed NurseTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA), Patrick Shanahan, Arrived at the facility and was greeted by the facility nurse. The Administrator was called and notified of the visit. The administrator was at a meeting and was unable to attend the annual. The facility nurse assisted in the annual. The inspection tool was used to complete the annual. The LPA had his temperature taken and COVID-19 protocol was followed before allowing the LPA to enter the home.

The home consists of 4 bedrooms and 2 bathrooms. There is no live in staff room. The smoke alarms and carbon monoxide detectors were tested and functioned properly. Two fire extinguishers were observed and were last serviced on 2/1/2022.

The facility is currently following their infection control plan and no deficiencies were observed during the visit.

Exit interview conducted and report issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2022
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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