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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609010
Report Date: 12/09/2023
Date Signed: 12/09/2023 01:48:04 PM

Document Has Been Signed on 12/09/2023 01:48 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 - INDEXFACILITY NUMBER:
197609010
ADMINISTRATOR:TAYO LABEODANFACILITY TYPE:
735
ADDRESS:17328 INDEX STTELEPHONE:
(626) 500-1430
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 4CENSUS: 4DATE:
12/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Yvette Cosme-LVNTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with LVN/staff, Yvette Cosme and explained the reason for the visit.

At approximately 9:45am, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. Smoke alarms and carbon monoxide are tested and observed to be operable. There are three (3) fire extinguisher in the facility: one (1) in the dining room, one (1) in the hallway in between bedrooms and one (1) in the garage. Extinguishers were observed to be full and last serviced on 02/10/23.

Kitchen: The kitchen was observed to be clean and sanitary. All the toxins, cleaning solutions and disinfectants are locked in the cabinet below the kitchen sink. Knives and sharps are observed to be locked in the kitchen cabinet. LPA found a sufficient amount of perishable and non-perishable food in the kitchen, properly stored.

Bedrooms: There were four (4) bedrooms designated for residents' use. All four bedrooms were properly furnished with appropriate beddings and linens with sufficient lighting.

Bathrooms: There are two (2) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 111 degrees Fahrenheit. No cleaning supplies were stored in the bathrooms.

Common Areas: These included the living room and dining area. The common areas were properly furnished. The fireplace is non-operable, but had a screen in place. No fireplace tools were present. 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: 12/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2023
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 - INDEX
FACILITY NUMBER: 197609010
VISIT DATE: 12/09/2023
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Surrounding Grounds: Entry/exits were free of obstruction. The backyard patio is covered. There is furniture, games and a basketball court that is appropriate for outdoor use. The outdoor area was free of hazards.

Garage: The garage is attached to the house. It is being used as laundry room, additional storage for frozen food and other supplies. Two (2) buckets of emergency food supplies and water is also kept in the garage. Cleaning solutions and laundry detergents are observed kept in the locked cabinet. Garage door is kept locked and inaccessible to the clients.

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 was observed to be inaccessible and stored in a secured cabinet located by the side entrance of the home. Medication Records were review for proper documentation. There are two (2) complete First Aid kits in the medication cabinet.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and Copy of the Report Issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2023
LIC809 (FAS) - (06/04)
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