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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601509
Report Date: 08/22/2023
Date Signed: 08/22/2023 12:48:53 PM

Document Has Been Signed on 08/22/2023 12:48 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:
08/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:04 AM
MET WITH:Martin Sy, AdministratorTIME COMPLETED:
12:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to staff Margarita Gonzalez Administrator Martin Sy arrived at the end of the visit. There are four (4) ambulatory developmentally disabled adults ages 18-59. The facility is licensed as a level 4i home vendored by San Gabriel/Pomona Regional Center. The inspection was completed using the CARE tools. Twelve (12) CARE tools domains were reviewed.

Infection Control:

  • Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility encourages hand washing and self symptom check of staff and visitors. COVID-19 isolation plan is in place. The facility has an Infection Control Plan and COVID-19 mitigation plan.


Physical Plant/Environment Safety:
  • 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, backyard with shaded patio furniture, and a detached garage.

  • The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors were tested and are operational. The facility has two (2) fully charged fire extinguishers. Knives, cleaning supplies, and toxic substances are locked and inaccessible to clients. There are no firearms or weapons stored at the facility.

  • Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.

  • The stove burners are not operable. Staff are using a lighter to ignite the burners. Citation issued.


*Narrative continues next page.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2023
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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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 NC - DE SALES
FACILITY NUMBER: 198601509
VISIT DATE: 08/22/2023
NARRATIVE
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Operational Requirements:
  • The Program Design is current.
  • Fire clearance has been approved for four (4) bedridden residents.
  • Care and supervision to meet the clients needs was observed. Special equipment and supplies are used by clients.
  • Surety bond was reviewed and is current.

Staffing:
  • A total of eleven (11) staff members provide care and supervision to the clients.
  • Staff transport residents in a facility van.

Personnel Records/Staff Training:
  • Administrator certificate expired 9/20/2022. Administrator is waiting for recertification to be processed.
  • Four (4) staff files were reviewed for criminal background clearance and training.
  • Personnel records have health/TB screenings, certifications, 1st Aid/CPR training, and CPI training. Staff (S4) has expired (5/25/23) 1st Aid/CPR certification. Citation was issued.

Client Rights/Information:
  • Physician orders, and personal rights were reviewed in client files.

Client Records/Incident Reports:
  • Four (4) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, IPP reports, personal rights, medical consent, nutritional assessments, and medication administration records. Personal & Incidental (P & I) monies/records were reviewed.

Food Service:
  • The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.
  • There are physician orders for modified diets in resident files.

See next page.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023
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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 NC - DE SALES
FACILITY NUMBER: 198601509
VISIT DATE: 08/22/2023
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Health Related Services:
  • Clients are assisted with self administration of prescription and non-prescription medications.
  • Centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions. 30-Day supply of medications were observed.

Incident Medical and Dental:
  • All clients have a Needs and Services Plan and COVID-19 vaccination cards on file.
  • Staff training was on file.

Disaster Preparedness, and Emergency Intervention:
  • A posted Emergency Disaster Plan LIC 610D containing emergency evacuation information was observed. However, form LIC 610D is not current. Licensee is required to have an emergency disaster plan/Disaster and Mass Casualty Plan. The plan shall be reviewed annually, updated as necessary, and maintained on file at the facility.
  • An emergency drill was conducted on 7/31/2023.


Emergency Intervention:
  • No manual restraints or seclusion are used with clients in care.

Per Title 22, California Code of Regulations, deficiencies were cited.


Exit interview conducted with Administrator Martin Sy. A copy of the report and appeal rights were issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/22/2023 12:48 PM - It Cannot Be Edited


Created By: Noemi Galarza On 08/22/2023 at 12:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ELWYN NC - DE SALES
FACILITY NUMBER: 198601509

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the 4 stove burners are not in safe working condition, staff are using a lighter to ignite the burners; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2023
Plan of Correction
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Administrator agreed to repair the faulty stove burners and/or replace the stove. Submit proof of repairs and/or purchase.
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in staff (S4's) 1st Aid /CPR card certification expired 5/25/2023; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2023
Plan of Correction
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Administrator agreed to submit proof of CPR/1st Aid training for staff (S4). Administrator shall review all staff files and ensure all staff have current certification.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023


LIC809 (FAS) - (06/04)
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