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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601509
Report Date: 08/19/2022
Date Signed: 08/19/2022 02:26:45 PM

Document Has Been Signed on 08/19/2022 02:26 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:HAZEL A. GATANFACILITY TYPE:
735
ADDRESS:610 N DE SALES STTELEPHONE:
(626) 872-6983
CITY:SAN GABRIELSTATE: CAZIP CODE:
91775
CAPACITY: 4CENSUS: 4DATE:
08/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:16 PM
MET WITH:Raven Warren, StaffTIME COMPLETED:
02:35 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 staff Raven Warren 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 4 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/emergency drill was conducted on 8/12/2022. Administrator certificate expires 6/9/2024.

The following were observed/inspected:
  • The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. The facility is equipped with a sprinkler system. Smoke and carbon monoxide detectors were tested and operational.
  • COVID-19 Infection Control Practices and signs that promote hand washing, cough/sneeze etiquette, and physical distancing were observed in the entrance, common areas, hallways, bathrooms and client rooms. There is a screening station at the entrance of the facility to screen visitors.
  • Each client's room is designated as a COVID-19 solation room if needed.
  • A posted Emergency Disaster Plan was observed.
  • Four (4) centrally stored client medication records were reviewed. Medications are documented properly and given as prescribed.
  • Staff were observed wearing mask. Clients do not wear masks due to disability and behaviors.
  • The kitchen was inspected and a sufficient supply of perishable for 2 days & non-perishable foods for 7 days was observed. observed.
  • Facility has at least a 30-day supply of Personal Protective Equipment (PPEs).
  • All staff have fingerprint clearances. Staff and resident files were not reviewed during today's visit.


Per California Code of Regulations, Title 22, there were NO deficiencies observed during the visit.
Exit interview was conducted with staff Raven Warren. A copy of the report was issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2022
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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