198601324-1-23-2025-28-AS-NGAA-DD82GG-20250123162306

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601324
Report Date: 01/23/2025
Date Signed: 01/23/2025 04:23:17 PM

Document Has Been Signed on 01/23/2025 04:23 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 - VISTA		FACILITY NUMBER:	198601324
ADMINISTRATOR/ DIRECTOR:	HAZEL ANGELI GATAN		FACILITY TYPE:	734
ADDRESS:	6034 N VISTA ST		TELEPHONE:	(626) 451-0550
CITY:	SAN GABRIEL	STATE: CA	ZIP CODE:	91775
CAPACITY: 4		CENSUS: 4	DATE:	01/23/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Sally Wu, RN		TIME VISIT/ INSPECTION COMPLETED:	01:21 PM

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Licensing Program Analysts (LPAs) Galarza and Nicol Wesley conducted an unannounced Required- 1 year visit. The purpose of the visit was explained to LVN Xuexiang Wu. House Manager/ RN Sally Wu arrived shortly after. The facility is an Adult Residential Facility for Persons with Special Health Care Needs (ARFPSHN) licensed to serve to serve adults over the age of 18 with developmental disabilities who are medically fragile and require 24-hour licensed nursing supports vendored by Eastern Los Angeles Regional Center. The facility provides transportation services and is equipped with 2 vans. The following 12 Care Compliance and Regulatory Enforcement (CARE) tool domains were utilized during the inspection.

The following were observed/inspected:

Infection Control: An Infection Control Plan was submitted to CCL and was available on site for review.

Physical Plant/Environment Safety: The facility is a single-story home that contains four (4) bedrooms fully equipped with mechanical lifts, two (2) bathrooms of which one (1) is equipped with a mechanical lift, a living room, family room, kitchen, dining room, laundry room, backyard shaded patio area, and attached garage. The facility's last fire inspection was conducted on 1/23/2024 by Echo Fire Protection Co.

The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Electrical smoke and sprinklers, and carbon monoxide detectors were tested. The facility has four (4) fully charged fire extinguishers. Cleaning supplies and toxic substances are inaccessible to clients. Water temperature readings measured between the required 105 - 120 degrees Fahrenheit. The facility maintains emergency food supply and water. Emergency Phone numbers, exit plan and programming schedules were posted. The building contains central air conditioning and heating. A 1st Aid Kit & Manual consisting of thermometer, tweezers, scissors, antiseptic, bandages, and gauze were observed. The facility has an operable generator.

Resident (R2's) bedroom door has chipped paint and facility walls, baseboards, and wall edges are in disrepair. A citation was issued.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ELWYN NC - VISTA	FACILITY NUMBER: 198601324
	VISIT DATE: 01/23/2025

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Operational Requirements: Fire clearance is approved for 4 bedridden residents. Care and supervision to meet the clients needs was observed. Special equipment [mechanical lifts and wheelchairs] are used for all residents. Surety bond is current.

Staffing: A total of 22 staff members provide care and supervision to the clients.

Personnel Records/Staff Training: Five (5) staff files were reviewed for criminal background clearance and training. Personnel records have health/TB screenings, certifications, and 1st Aid/CPR training. Staff training is conducted monthly. Administrator certificate expires 6/9/2026.

Client Rights/Information: Personal rights were posted and in client files.

Client Records/Incident Reports: Four (4) client files were reviewed. They contained Individual Health Care Plans (IHCP), IPP, medical assessments, admission agreements, personal rights, medical consent, dietician report, consultant logs, Personal & Incidental (P & I) monies/records, TB clearance, and Medication Administration Records. 30-day supply of client medications were observed locked and given as prescribed. P & I money records were reviewed. Money was missing and is being addressed on a separate CM report.

Food Service: The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. All sharps were locked. Two (2) clients have a G-Tube and two (2) clients require a pureed diet.

Health Related Services: Residents are assisted with self administration of prescription and non-prescription medications. Centrally stored resident medication records were reviewed and are given according to Physician directions. 30-Day supply of medications were observed.

Incident Medical and Dental: All residents have updated consultant assessments, Physician Reports, physician orders, and COVID-19 vaccination cards on file.

Disaster Preparedness, and Emergency Intervention: Emergency Disaster Plan was reviewed. The plan shall be reviewed annually, updated as necessary, and maintained on file at the facility. First Aid Kit and Manual were observed. The last emergency drill was conducted on 1/3/2025.

Emergency Intervention: No manual restraints or seclusion is used in the facility.

Per Title 22, California Code of Regulations, a deficiency is being cited.

Exit interview conducted with Administrator Hazel Gatan. A copy of the report and appeal rights were issued.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/23/2025 04:23 PM - It Cannot Be Edited

Created By: Noemi Galarza On 01/23/2025 at 02:44 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ELWYN NC - VISTA	FACILITY NUMBER: 198601324
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that Resident (R2's) bedroom door has chipped paint and facility walls, baseboards, and wall edges are in disrepair, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/20/2025
	Plan of Correction
1 2 3 4	Administrator stated that a paint work order was initiated in August 2024. However, the maintenance paint job has not begun. Submit picture proof of correction along with a copy of the work order service receipt. If a POC extension is needed submit by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Lisa Hicks

LICENSING EVALUATOR NAME:

Noemi Galarza

LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

LIC809 (FAS) - (06/04)

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