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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609743
Report Date: 03/25/2022
Date Signed: 03/25/2022 02:26:11 PM

Document Has Been Signed on 03/25/2022 02:26 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 - QUARTZFACILITY NUMBER:
197609743
ADMINISTRATOR:JOSEPH TIGHEFACILITY TYPE:
737
ADDRESS:8033 QUARTZ AVETELEPHONE:
(925) 626-7014
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY: 2CENSUS: 2DATE:
03/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Stephen WamalaTIME COMPLETED:
02:30 PM
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A Required One (1) year - Infection Control visit was conducted today by Licensing Program Analyst (LPA) Michael Cava. LPA met with the administrator, Stephen Wamala and stated the purpose of the visit. LPA observed two (2) residents at the facility during the visit. This is an Enhanced Behavioral Support Home (EBSH) Adult Residential Facility.

The tour of the physical plant was conducted at 11:30am and the following were noted:

The main door is the only entrance being utilized for entry. There is a sign on the door that everyone entering at the facility must wear a mask and must be screened. The screening area is located at the entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened by staff upon entry. All staff were observed to be wearing a mask.

The facility submitted an approved Mitigation Plan.

Signs to wear a mask and other COVID 19 prevention protocol signs were posted on the walls. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with covers.

The facility has a sufficient supply of PPEs. Designated visiting area is in the living room or the backyard.

Resident rooms: The facility has a fire clearance for two non-ambulatory residents in rooms 2, 3, and 4. Room 1 is ambulatory only. Rooms 1 and 4 currently identified for resident use. Rooms 2, 3, and 4 have direct exits to the outside. Resident rooms have appropriate lighting, furniture, bedding, and linens. At the time of the visit, all exit doors had functional auditory alarms. Rooms 2 is used an office. Room 3 is used as an excercise room.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2022
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 - QUARTZ
FACILITY NUMBER: 197609743
VISIT DATE: 03/25/2022
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Bathrooms: LPA toured resident bathrooms and checked to make sure bathrooms were clean and in good repair. The hot water temperature measured between at 105 degrees F. Towels and washcloths are not shared. Residents have sufficient amounts of supplies for personal hygiene items which is provided by the Licensee.

Common Areas: LPA toured all common areas of the facility. LPA observed common areas to be clean and furniture in good repair. The facility maintains a comfortable temperature at 72 degrees F. LPA observed a current fire extinguisher maintained in the kitchen. The smoke/carbon monoxide detectors are operational. There are no issues with Fire Clearance.

Outside areas: LPA toured the outside area of the facility. There are no bodies of water which is unsecured. Passageways were clear of obstruction.

The garage is attached to the home. It is used as an additional office space and storage for extra perishable and non-perishable food.

Food Inspection: LPA conducted a food inspection tour. LPA observed there to be sufficient stock of two- perishable and seven-day non-perishables foods. Snacks and beverages are available for clients in the facility when they want. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Cleaning supplies, pesticides or toxins were stored separately and locked away.

Laundry: There is enough linen available to change weekly or more if need.

Pursuant to CA code of Regulations Title 22 or Health and Safety Code. No deficiencies observed during the day's visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
LIC809 (FAS) - (06/04)
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