198601509-8-30-2024-28-AS-NGAA-D8MQZ4-20240830123607

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601509
Report Date: 08/30/2024
Date Signed: 08/30/2024 12:36:14 PM

Document Has Been Signed on 08/30/2024 12:36 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 CA - DE SALES		FACILITY NUMBER:	198601509
ADMINISTRATOR/ DIRECTOR:	MARTIN SY		FACILITY TYPE:	735
ADDRESS:	610 N DE SALES ST		TELEPHONE:	(626) 872-6983
CITY:	SAN GABRIEL	STATE: CA	ZIP CODE:	91775
CAPACITY: 4		CENSUS: 3	DATE:	08/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Rhea Castillo, Interim Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:40 PM

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Licensing Program Analyst (LPA) Noemi Galarza made an unannounced Required - 1 year annual inspection visit. The purpose of the visit was explained to House Manager Efren Quintero whom assisted with the visit. LVN Interim Administrator Rhea Castillo arrived later. The facility is licensed as a level 4i Adult Residential Facility (ARF) that serves developmentally disabled residents under age 59, and is vendored by Eastern Los Angeles Regional Center. The facility is a single story home located in a residential neighborhood that is 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 following 12 (CARE) tool domains were utilized during the inspection.

Infection Control: The facility has an Infection Control Plan in place.

Physical Plant/Environment Safety: 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 a sprinkler system and three (3) fully charged fire extinguishers. Hot water temperature readings measured between the required 105 - 120 degrees Fahrenheit. Storage areas for cleaning solutions/toxins, knives, and hazardous items were inaccessible to clients.

Operational Requirements: Fire clearance is approved for four (4) bedridden residents. Care and supervision to meet the clients needs was observed. No special equipment and supplies are used by clients. Facility manages residents P & I monies. Facility has a current Surety Bond.

Staffing: A total of 12 staff members provide care and supervision to the clients.

Personnel Records/Staff Training: Six (6) staff files were reviewed. Criminal background clearance, in-service training, Pro-Act/CPI training, 1st Aid/CPR training, and health screening.

Administrator Martin Sy is no longer the Administrator. The facility has 2 Interim Administrators at this time. A technical advisory was issued.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024

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 CA - DE SALES	FACILITY NUMBER: 198601509
	VISIT DATE: 08/30/2024

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Resident Rights/Information: Resident Personal Rights poster is posted in the dining room and resident rooms. Internet access is available for residents. Physician's orders are on file. Two (2) residents require a modified diet.

Resident Records/Incident Reports: Three (3) resident files were reviewed containing admission agreements, Physician's Reports, IPPs, medical/functional assessments, Behavior Reports, TB clearance, personal rights, medical consent, medication records, and P & I records. Files have not been updated with HCBS Tenant/Landlord Rights and Responsibilities Agreement.

*Note: Residents (R1 & R2) are over the age of 59. Therefore, an Age Exception is required because the census exceeds 50% of allowable residents over the age of 60.

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.

Health Related Services: Residents are assisted with self administration of prescription and non-prescription medications. Medications 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 reviewed.

Incident Medical and Dental: Files have Needs and Services Plan and updated medical assessments, and COVID-19 vaccination cards on file. Staff training was reviewed.

Disaster Preparedness, and Emergency Intervention: LIC 610D "Emergency Disaster Plan/Disaster and Mass Casualty Plan" is posted.

The last Fire/Emergency Drill was conducted on 8/8/2024, within 6 months of Title 22 requirement.

Emergency Intervention: Facility uses Pro-Act de-escalation and crisis reduction techniques. Staff training is current.

A deficiency was cited.

Exit interview was conducted with Interim Administrator Rhea Castillo. A copy of the report and appeal rights were issued.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/30/2024 12:36 PM - It Cannot Be Edited

Created By: Noemi Galarza On 08/30/2024 at 11:23 AM

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 CA - DE SALES	FACILITY NUMBER: 198601509
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85068.4(g)

Acceptance and Retention Limitations. If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients, or 25 percent of the census in facilities with a capacity over six, the licensee must request an exception in order to accept or retain the individual. The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section above in that there are a total of 3 residents, of which two (2) [R1 & R2] are over the age of 59, and an Exception Waiver for residents is not in place. The census exceeds 50% of allowable residents over the age of 60, which poses/posed a potential health, safety, or personal rights risk to persons in care.
	POC Due Date: 09/27/2024
	Plan of Correction
1 2 3 4	Licensee shall submit Age Exception requests for R1 & R2 by POC due date, and/or submit written plan to relocate residents. If an extension is required submit a written request by the due date.

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: 08/30/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024

LIC809 (FAS) - (06/04)

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