<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609010
Report Date: 01/21/2025
Date Signed: 01/21/2025 11:51:13 AM

Document Has Been Signed on 01/21/2025 11:51 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/
DIRECTOR:		TAYO LABEODANFACILITY TYPE:
735
ADDRESS:17328 INDEX STTELEPHONE:
(626) 500-1430
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 4CENSUS: 4DATE:
01/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:06 AM
MET WITH:Yvette Cosme-LVNTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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 Analysts (LPAs) Nadia Shahbazian and Michael Cava conducted an Annual Required visit and inspection of the facility. LPAs met with LVN/staff, Yvette Cosme and explained the reason for the visit.

At approximately 9:00am, with the assistance of staff, LPAs took a tour of the physical plant. The facility is a one story building that houses level 4I clients. The smoke alarms and carbon monoxide dual. Smoke alarms were tested and observed to be operable. There are two (2) fire extinguisher in the facility: one (1) in the dining room, and one (1) in the hallway between two bedrooms. Fire extinguishers were observed to be fully charged. Service date was 02/10/24.

Kitchen: The kitchen was observed to be clean and sanitary. All the toxins, cleaning solutions and disinfectants are locked. LPAs did not see any cleaning supplies out and accessible during the day's visit. Knives and sharps were observed to be locked in a 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 115 degrees Fahrenheit. No cleaning supplies were stored in the bathrooms.

Common Areas: These included the living room and dining area. The living room is furnished with two couches, one television, entertainment center and three (3) exercise equipment. There is fireplace that is
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 01/21/2025
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
26
27
28
29
30
31
32
screened and non-operable. No fireplace tools present. The dining room has a table is large enough to seat all four (4) clients.

Staff Office/Work Station: Staff work station is located by the kitchen. Spare office and vehicle keys are kept inside the desk.

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. Entry is from the outside only. It is being used as laundry room and additional storage space for PPE and emergency food and water supply. Cleaning solutions and laundry detergents are kept in the locked cabinet. Moreover, both entrance to the 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 and manual 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: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
LIC809 (FAS) - (06/04)
Page: 2 of 2