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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601324
Report Date: 02/24/2024
Date Signed: 02/24/2024 11:50:07 AM

Document Has Been Signed on 02/24/2024 11:50 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ELWYN NC - VISTAFACILITY NUMBER:
198601324
ADMINISTRATOR:HAZEL ANGELI GATANFACILITY TYPE:
734
ADDRESS:6034 N VISTA STTELEPHONE:
(626) 451-0550
CITY:SAN GABRIELSTATE: CAZIP CODE:
91775
CAPACITY: 4CENSUS: 3DATE:
02/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:42 AM
MET WITH:Linda Loeung - Caregiver/Registered NurseTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Linda Loeung (Caregiver/Registered Nurse), who assisted with the inspection. The purpose of the visit was explained.

The facility is licensed as an Adult Residential Facility for Persons with Special Health Care Needs (ARFPSHN) to serve five (4) adults ages 18 through 59 and 4 may be bedridden. The facility currently has 3 bedridden clients that are serviced though Eastern Los Angeles Regional Center.

The facility is a single-story home located in San Gabriel, Ca. A tour of the facility includes: living room, dining room, kitchen, laundry room, 4 client bedrooms, 1 client bathroom, 1 staff bathroom, attached garage, front yard and back yard.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:


Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan.
Physical Plant & Environment Safety: Clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The outdoor and passageways are free of obstruction. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested in the client bathroom and measured within the required range of 105-120 degrees. The front and back yard are free of debris/hazards. All storage areas for cleaning solutions, and toxins are stored in a locked cabinet. The knives and sharp items are properly stored and locked securely. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguishers were observed and are fully charged. (Continued on 809-C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2024
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ELWYN NC - VISTA
FACILITY NUMBER: 198601324
VISIT DATE: 02/24/2024
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Operational Requirements: There are currently 3 bedridden clients residing at the facility. Facility has the appropriate fire clearance, are aware of the reporting requirements and have proper plan of operation.
Personnel Records-Training: Staff files are maintained at the facility and have current First-Aid/CPR/AED training, criminal record clearance and sufficient on-going training. There appears to be sufficient staffing at all times in the facility. Administrator Hazel Angeli L Gatan certificate expires on 6/9/2024. LPA reviewed 3 staff files during todays visit with no issues observed
Client Records-Incident Reports: Client files are kept in a locked cabinet and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. LPA reviewed 3 client files during todays visit with no issues observed
Client Rights-Information: Client personal rights poster is posted within the facility.
Food Service: There are 2 clients that are on a restricted enteral feeding diet and the facility has sufficient nutrients for the clients. The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables for the remaining client.
Health Related Service: Staff designated to administer medication have the proper training on file.
Medication is centrally stored in both a locked medical cabinet and locked kitchen cabinets, making them inaccessible to clients.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Emergency/Earthquake/Disaster Drills are conducted monthly with the last drill done on 2/6/24.

During todays visit LPA conducted 2 staff interviews and 0 client interviews as clients are nonverbal.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit.

Exit interview held and a copy of the report was provided to Linda Loeung.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2024
LIC809 (FAS) - (06/04)
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