197610347-1-4-2023-31-AS-APAA-CMRSAR-20230104124245

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610347
Report Date: 01/04/2023
Date Signed: 01/04/2023 12:43:17 PM

Document Has Been Signed on 01/04/2023 12:43 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:	ELWOOD HOME CARE LLC		FACILITY NUMBER:	197610347
ADMINISTRATOR:	MANLAPAZ, EILEEN		FACILITY TYPE:	740
ADDRESS:	4099 ELWOOD AVENUE		TELEPHONE:	(661) 526-5950
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93552
CAPACITY:	6	CENSUS: 0	DATE:	01/04/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Eileen Manlapaz, Administrator		TIME COMPLETED:	01:15 PM

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At 10:40am Licensing Program Analysts (LPA) Angela Panushkina conducted an announced Pre-Licensing visit to the above facility and met with applicant Elwood Home Care, LLC. LPA conducted an entrance interview with the Administrator.

Fire Clearance dated 10/28/2022 was received for five (5) non-ambulatory, one (1) bedridden (in room #4) and three (3) hospice residents. The purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. The facility is a single-story building. Today's site visit consisted of LPA touring the physical plant inside and outside and observed the following:

The facility has a total of five (5) bedrooms, four (4) of which are designated for resident use. Resident bedrooms were observed to be appropriately furnished. There are two (2) bathrooms in the facility designated for resident use and were observed to have non-skid mats and appropriate grab bars installed. The facility will have awake staff at night.

The common areas (living room, kitchen and dining areas) were appropriately furnished and lighting was adequate. The living room has a television and comfortable furniture. The fire extinguisher is located in the kitchen and was purchased on 9/21/2022. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 11:05am they were tested and observed to be operational. At 11:30am the hot water was tested and measured at 120.0°F. There is a functioning telephone on the premises. An emergency exit plan/sketch is posted by the entrance. Medications will be stored in a locked cabinet in the kitchen. The first aid kit is readily available. Resident and staff records will be stored in a locked cabinet by the living room. The kitchen knives are stored in a locked cabinet under the kitchen sink. The laundry area is located in an attached garage and LPA observed all detergents, cleaning supplies and other toxins are kept locked.

Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023

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: ELWOOD HOME CARE LLC	FACILITY NUMBER: 197610347
	VISIT DATE: 01/04/2023

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The necessary precautions have been made to the facility to safely house dementia residents such as auditory alarms on all doors and locked areas for centrally stored medications. Facility appears to be clean and in good repair. Appliances in the kitchen appeared to be functional.

There is a sitting area in the backyard for residents to conduct outdoor activities. The backyard is fenced. There is no body of water in the facility.

Component III was conducted with the Administrator.

Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved.

Exit interview was conducted with the Administrator and a copy of this report was provided.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023

LIC809 (FAS) - (06/04)

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