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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609743
Report Date: 11/28/2023
Date Signed: 11/28/2023 12:41:17 PM

Document Has Been Signed on 11/28/2023 12:41 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ELWYN CALIFORNIA - QUARTZFACILITY NUMBER:
197609743
ADMINISTRATOR:STEPHEN WAMALAFACILITY TYPE:
737
ADDRESS:8033 QUARTZ AVETELEPHONE:
(925) 626-7014
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY: 2CENSUS: 2DATE:
11/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Stephen WamalaTIME COMPLETED:
12:30 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 Analyst (LPA) Tuesday Cabiness conducted an annual inspection and met with Administrator Stephen Wamala, who was informed the reason of the visit. Upon entry, LPA observed a sign-in sheet, and cleaning station. There were (2) clients present during the visit; as well as (7) Registered Behavior Technicians. This is an Enhanced Behavioral Support Home (EBSH) Adult Residential Facility. 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. Licensing signs also observed on the walls.

The following was observed during the inspection: Kitchen: LPA observed Licensing requirement of (7) day nonperishable, and (2) day perishable, with extra refrigerator located in the garage area. Food was properly wrapped, and appliances were functional, clean, and in good repair. Chemicals, household supplies, and knives, are stored in garage area were locked and secured. Living/dining: All indoor passageways were free from obstruction; inside temperature was comfortable, with adequate lighting, and all areas were clean and appropriately furnished for clients comfort. Bedrooms: The facility has (4) bedrooms; with (2) rooms for clients; (1) room used for gym purposes; and (1) room is the staff office. The facility has a fire clearance for two non-ambulatory clients in rooms 2, 3, and 4. Room 1 is ambulatory only. Rooms 1 and 4 are currently identified for clients. Rooms 2, 3, and 4 have direct exits to the outside. Client rooms have appropriate lighting, furniture, bedding, and linens. At the time of the visit, all exit doors had functional auditory alarms. There are sufficient linens observed and available. Bathrooms: There are (2); all were clean, with soap and towels. Hot water measured at 119.7 degrees Fahrenheit. Surrounding Grounds: There were no visible hazards; passageways were free from obstruction and gates were easily accessible to open. There is covered furniture for client's comfort and use. Fire extinguisher fully charged. First aid kit furnished fully equipped. Smoke alarms and carbon monoxide detectors are functioning. The facility has a sufficient supply of PPE supply.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/28/2023
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ELWYN CALIFORNIA - QUARTZ
FACILITY NUMBER: 197609743
VISIT DATE: 11/28/2023
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
Record review: A complete record review of staff and clients were conducted; all required documents were in files, including training and client medical assessments. There were no medication errors. All staff are vaccinated; and only (1) client.

No citation issued; exit interview and copy of report provided.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2