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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601324
Report Date: 02/15/2022
Date Signed: 02/15/2022 12:54:15 PM

Document Has Been Signed on 02/15/2022 12:54 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ELWYN NC - VISTAFACILITY NUMBER:
198601324
ADMINISTRATOR:CESAR GOMEZFACILITY TYPE:
734
ADDRESS:6034 N VISTA STTELEPHONE:
(626) 451-0550
CITY:SAN GABRIELSTATE: CAZIP CODE:
91775
CAPACITY: 4CENSUS: 3DATE:
02/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:12 AM
MET WITH:Cesar Gomez - Administrator TIME COMPLETED:
12:15 PM
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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced annual visit at the facility with focus on infection control domain, food and medication review. LPA Flores met with Cesar Gomez administrator and explained the reason for the visit.

The facility is licensed as an Adult Residential Facility to serve 4 adults with Special Health Care Needs (ARFPSHN) and is vendor through Eastern Los Angeles Regional Center with a staff/client ratio of 1:1. The facility is a single story home, with 4 bedrooms, 2 bathrooms, a dining room, living room, family room, kitchen, laundry room, garage, and an outside shaded backyard located in residential neighborhood. No large bodies of water were observed.
LPA Flores tour the facility with Cesar Gomez administrator and Sally Wu nurse and observed the following:
Living room has a covered fired placed, dinning room, and family room have sufficient lighting and space. Kitchen area was observed to have food supplies of 2 days of perishables and 7 days of non-perishables. Knives were locked in a drawer to the right of kitchen sink. Overflow medication and medical supplies locked in cabinets in the kitchen. All bedrooms have sufficient lighting, furniture, and required bedding. Fire extinguisher was observed outside Bedroom #1 last checked on 6/21. Bathroom #1 has grab bars, mats, a shower bed, water temperature was tested at 115.7 degrees F which is within the required 105 - 120 degrees F. Bathroom #2 is used by staff only. Smoke/Carbon Monoxide detectors are interlace, were tested and are in working condition. Medication cart was observed locked, located in the dinning room. LPA reviewed medication for client #1(C1) and #2(C2) and files for C1, C2 and staff #1 and #2. Administrator certificate was observed for Cesar Gomez #6041407735 expiration date: 11/24/22.
Facility is following COVID 19 recommendations; screening logs were observed for visitors, staff, and clients. PPE supplies were observed for over 30 days. Staff have been fit tested for N95 and were observed wearing face mask at the facility. Signs were posted throughout and near sinks, hand soap and paper towels available.
No deficiencies were given during this visit.
Exit interview was conducted with Cesar Gomez administrator and a copy of this report was provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2022
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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