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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601480
Report Date: 09/07/2022
Date Signed: 09/07/2022 02:49:52 PM

Document Has Been Signed on 09/07/2022 02:49 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 CALIFORNIA - HALIFAXFACILITY NUMBER:
198601480
ADMINISTRATOR:WU, MIAOLI (CARRIE)FACILITY TYPE:
735
ADDRESS:5029 HALIFAX RDTELEPHONE:
(626) 941-6381
CITY:TEMPLE CITYSTATE: CAZIP CODE:
91780
CAPACITY: 4CENSUS: 4DATE:
09/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Administrator, Adalid Solano-GutierrezTIME COMPLETED:
03:30 PM
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On 9/07/2022, Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced annual inspection focusing on the Infection Control Domain. LPA was allowed entry into this home by Rhea Lynn Castillo, House Manager. LPA Pena was greeted by Administrator Adalid Solano-Gutierrez and discussed the purpose of today's visit. The facility cares for intellectually disabled adults and is vendorized by Eastern Los ANgeles Regional Center (ELARC). It is approved to serve four (4) Non-ambulatory Developmentally Disabled Adults. LPA observed the facility plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed staff and resident files. This single-story home contains four (4) bedrooms, two (2) bathrooms, a living room, activity area, kitchen, office, dining area, backyard, and attached garage. LPA observed that the facility does not have a swimming pool or other bodies of water. LPA Pena reminded the Administrator to send the Infection Control Plan and he sent it via fax to CCLD today.

At 1:06pm LPA Pena along with the Administrator toured the facility.

The following was observed/inspected:
  • The facility had a universal entrance screening area including a thermometer, PPE supplies, screening logs, and sign-in sheet.
  • COVID-19 signage was placed in several areas of the facility.
  • Facility maintained a 30-day supply of PPE located in the supply closets in the garage.
  • The laundry room was clean and located in the garage. It has cleaning supplies inaccessible to residents.


Continued on LIC 809-C..........
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2022
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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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 CALIFORNIA - HALIFAX
FACILITY NUMBER: 198601480
VISIT DATE: 09/07/2022
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  • The kitchen was inspected. There was a sufficient supply of 3-day perishables and 7-day supply of non-perishable foods. All the appliances were clean and working properly.
  • Cleaning solutions and sharps were locked in their respective cabinets and inaccessible to clients.
  • Water temperatures were measured in the kitchen and bathrooms. Kitchen's hot water temperature read 113.9 degrees F. Full-bathroom #1 hot water temperature read 113.4 degrees F. The hot water in the half-bathroom read 113.1 degrees F. All readings were within the required 105 - 120 degrees.
  • All four (4) client bedrooms were toured. Each bedroom has a door alarm, bed, linen, dresser, night stand, light, chair and sufficient closet space.
  • Both bathrooms, 1 full and 1 half bathroom, have the required grabs bars, non-skid materials and contained hygiene supplies including liquid soap, paper towels, and toilet paper.
  • Medications were locked, centrally stored, and given as prescribed by the nurses on-duty. Medications were reviewed for random clients and facility maintained a 30-day supply of medications. Clients' medications were reviewed to confirm medication was given as prescribed and was documented properly.
  • Staff wore face masks throughout their shift.
  • The common areas such as activity room and dining room were clean and have the required furniture. Furniture and group activities were spaced to encourage physical distancing.
  • The backyard has a shaded area and sitting area and has been designated as the visitor area during the COVID-19 pandemic.
  • Exit doors have auditory devices that were operating at the time of the visit.
  • There were three (3) fire extinguishers in the home, located in the hallway, garage and kitchen. All fire extinguishers were observed to be fully charged and last serviced on Feb. 2, 2022.
  • Smoke detectors/carbon monoxide detectors were present and operable.
  • Clients files were reviewed to confirm emergency contact is updated and residents have health screenings and or vaccinations.
  • Three (3) staff files were inspected and contained required health screenings, criminal record clearances, and training certificates. Administrator certificate expires 6/15/2023. Staff files were reviewed to confirm health screenings and fingerprint clearances.

There were no deficiencies cited at this time. An exit interview was conducted and a copy of this report was provided to the Administrator, Adalid Solano.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022
LIC809 (FAS) - (06/04)
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