<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601480
Report Date: 12/08/2023
Date Signed: 12/08/2023 12:39:09 PM

Document Has Been Signed on 12/08/2023 12:39 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:
12/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:43 AM
MET WITH:Raymond Villaveza - Licensed Psychiatric Technician (LPT)TIME COMPLETED:
12:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Raymond Villaveza -LPT and explained the reason for the visit. Administrator and House manager arrived 15 minutes later.

Facility is licensed to serve four (4) non-ambulatory Developmentally Disabled Adults between the ages of 18-59 years old. Facility is located in a residential area and consist of a single-story home with four (4) bedrooms, two (2) bathrooms, a living room, activity area, kitchen, office, dining area, backyard, and an attached garage.

LPA toured the facility with Raymon Villaveza and observed the following:
Facility is in good repair indoor and outdoor. Living room has seating furniture, and fireplace is cover with plexiglass. Dining/activity area are clean and in good repair. Kitchen area was observed clean, cleaning supplies and sharps were observed inaccessible to clients. Food supplies were observed sufficient for at least 2 days of perishables and 7 days of non-perishables. Each client bedroom (4) has sufficient lightning, furniture, and bedding supplies. Bathrooms (2) were observed in good repair with grab bars and skid strips, water temperature was tested between 113.5-114.4 which is within the required 105-120 degrees F. Medication cart was observed locked and medication refrigerator has a locked container inside. Carbon monoxide/smoke detectors were observed throughout the facility, were tested and are in working condition. Fire extinguisher was observed and last checked on 1/13/23. Laundry area is located in the garage and additional supplies were stored in the garage as well. Backyard is clean and has a covered seating area. No large bodies of water were observed.
Flies and medication were reviewed for 4 clients and 5 staff files were reviewed. Emergency Disaster file and Infection Prevention file were reviewed. Administrator Certificate #6059819735 exp 6/15/25 was reviewed.
No Deficiencies were noted during this visit. Technical violations and advisories were noted.
Exit interview was conducted with Adalid Solano and a copy of this report was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6