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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601480
Report Date: 09/12/2023
Date Signed: 09/12/2023 12:02:43 PM

Document Has Been Signed on 09/12/2023 12:02 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ELWYN CALIFORNIA - HALIFAXFACILITY NUMBER:
198601480
ADMINISTRATOR:ADALID SOLANO-GUTIERREZFACILITY TYPE:
735
ADDRESS:5029 HALIFAX RDTELEPHONE:
(626) 941-6381
CITY:TEMPLE CITYSTATE: CAZIP CODE:
91780
CAPACITY: 4CENSUS: 4DATE:
09/12/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Alalid Solano-GutierrezTIME COMPLETED:
12:15 PM
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LPA Ranirez conducted an unannounced case management visit on 9/12/23 in regard to Special Incident Report (LIC 624) dated 8/27/23. LPA Ramirez was met by Staff #2 (S2) and explained the purpose of the visit. Administrator Adalid Solano-Gutierrez arrived shortly after to assist with the visit.

LPA Ramirez requested and obtained copies of client roster, staff roster, interview with staff 1 – 2, (S1- S2), copies of client#1 (C1): Identification and Emergency Information, Physician’s Report dated 6/5/23, Radillogy Report dated 8/28/23, Eastern Los Angeles Regional Center Quarterly Review Form dated 9/26/22, San Gabriel Valley Med Center discharge dated 8/27/23, Pacific Orthopaedic Medical Group Inc History and Physical dated 8/31/23, copies of Staff #3 (S3): Personnel Record, current CPR/First Aid, TB Screening, Fingerprint Clearance, and various Elwyn in-service training records.

Due to time constraints LPA Ramirez may return at a later time to gather additional documents and interviews. No deficiencies were issued and a copy of this was provided to Administrator Solano-Gutierrez.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2023
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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