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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601510
Report Date: 05/16/2022
Date Signed: 05/16/2022 04:22:52 PM

Document Has Been Signed on 05/16/2022 04:22 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 - DOREENFACILITY NUMBER:
198601510
ADMINISTRATOR:CALUNGSAD, MARY KRISTINEFACILITY TYPE:
734
ADDRESS:5116 DOREEN AVETELEPHONE:
(626) 941-6562
CITY:TEMPLE CITYSTATE: CAZIP CODE:
91780
CAPACITY: 5CENSUS: 5DATE:
05/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Jon O'Campo, House ManagerTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection with the focus of the Infection Control domain. LPA met with the House Manager, Jon O'Campo, who assisted with the inspection. The purpose of the visit was explained. The facility is licensed as an Adult Residential Facility for Persons with Special Health Care Needs (ARFPSHN) to serve five (5) adults ages 18 through 59 and 5 may be bedridden.

LPA toured the facility and observed the following:
The facility has 5 bedrooms, 2 bathrooms, living room, sensory room, dining room, kitchen, office area, and an attached garage. The clients' rooms have the required furniture and well maintained. There are no items obstructing the passageways. There are no bodies of water on the premises. LPA observed signage throughout the facility and in the restrooms for hand washing hygiene. Staff on duty were all wearing face coverings. PPE supplies for at least 30 days are observed. LPA observed sufficient food supplies for all clients on a modified diet. Knives, cleaning solutions, and disinfectants are stored and locked making them inaccessible to clients. The fire extinguishers were last inspected on 3/22/22. The medications are centrally stored and locked. The facility is continuing to follow COVID-19 strictest guidance. LPA reviewed all 5 clients' medications and observed a discrepancy on one of Client #2's medication. The medication Eliquis tab 2.5 mg morning bubble pack had day 1 and day 12 already popped out of the pack which is out of sequential order. There was no reference to the date in which it was given.

The deficiency is issued on the LIC809D. An exit interview was conducted and a copy of this report along with appeal rights were given to Staff.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2022
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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Document Has Been Signed on 05/16/2022 04:22 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 05/16/2022 at 03:51 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 - DOREEN
FACILITY NUMBER: 198601510

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)(5)(B)
80075 Health Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
(5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, providing all of the following requirements are met:
(B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above for Client #2 in which the medication Eliquis Tab 2.5 MG morning tablet (off cycle) were not given in sequential order which poses a potential health, safety risk to persons in care.
POC Due Date: 05/20/2022
Plan of Correction
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The Adminstrator shall conduct an inservice training with staff handling medications to ensure the off-cycle medication is noted with the date(s) in which it was administered to the client or develop a consistency plan for off cycle medication. The POC shall be submitted to LPA by 5/20/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2022


LIC809 (FAS) - (06/04)
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