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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601509
Report Date: 09/08/2021
Date Signed: 09/14/2021 01:11:40 PM

Document Has Been Signed on 09/14/2021 01:11 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 - DE SALESFACILITY NUMBER:
198601509
ADMINISTRATOR:EDWARD VELARDEFACILITY TYPE:
735
ADDRESS:610 N DE SALES STTELEPHONE:
(626) 872-6983
CITY:SAN GABRIELSTATE: CAZIP CODE:
91775
CAPACITY: 4CENSUS: 4DATE:
09/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:41 PM
MET WITH:Edward Velarde, AdministratorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Edward Velarde and explained the purpose of the visit. There are 4 ambulatory developmentally disabled, level 4i clients in the home. The facility is a single story home licensed for bedridden residents located in a residential neighborhood. It consists of 4 bedrooms, 2 bathrooms, dining room, kitchen, living room, outdoor patio, and a detached garage. The last fire drill was conducted on 9/2/2021. Administrator certificate expires 5/30/2022.

The following were observed/inspected:
  • COVID-19 Infection Control Practices were observed in common areas, isolation rooms/wing areas, and resident rooms. COVID-19 infection control signs were observed in all common rooms and hallways.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing. Furniture was observed to be at least 6ft apart.
  • Facility has one (1) designated isolation room.
  • Two (2) centrally stored resident medication records were reviewed.
  • All staff were observed wearing mask.
  • Due to client's disability and behaviors none of the clients in care were observed wearing masks.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
  • A posted Emergency Disaster Plan was observed.
  • Sufficient supply of Personal Protective Equipment (PPEs) was observed. .
  • Staff and resident files were not reviewed during today's visit.


There were no deficiencies cited.

Exit interview was conducted with Administrator Edward Velarde. A copy of the report was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2021
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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