198601510-5-11-2023-28-AS-THEA-CRQSXT-20230511141628

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601510
Report Date: 05/11/2023
Date Signed: 05/11/2023 02:16:34 PM

Document Has Been Signed on 05/11/2023 02:16 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	ELWYN NC - DOREEN		FACILITY NUMBER:	198601510
ADMINISTRATOR:	HAZEL ANGELI GATAN		FACILITY TYPE:	734
ADDRESS:	5116 DOREEN AVE		TELEPHONE:	(626) 941-6562
CITY:	TEMPLE CITY	STATE: CA	ZIP CODE:	91780
CAPACITY: 5		CENSUS: 5	DATE:	05/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:57 AM
MET WITH:	Jon O'Campo		TIME COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with the RN 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 utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan. Physical Plant & Environment Safety: The facility has 5 bedrooms, 2 bathrooms, living room, dining room, kitchen, office area, and an attached garage. Clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The outdoor and passageways are free of obstruction. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested throughout the facility and measured between 115.8 – 118.0 degrees F, these are within the required range of 105-120 degrees. The front and back yard are free of debris/hazards. All storage areas for cleaning solutions, and toxins are stored in a locked cabinet. The knives and sharp items are properly stored and locked securely. The last Fire/Emergency Drill was conducted on 2/8/2023. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguishers were observed and are fully charged. (Continued on 809-C)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ELWYN NC - DOREEN	FACILITY NUMBER: 198601510
	VISIT DATE: 05/11/2023

NARRATIVE

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Operational Requirements: There are currently 5 ambulatory clients residing at the facility. Facility has the appropriate fire clearance, are aware of the reporting requirements and have proper plan of operation.
Personnel Records-Training: Staff has criminal record clearance. Staff has current first aid and CPR. Staff files are maintained at the facility in the office area of the facility. Staff have current CPR/first aid training and sufficient on-going training. There appears to be sufficient staffing at all times in the facility. Administrator Hazel Angeli L Gatan certificate expires on 6/9/2024.
Client Rights-Information: Client personal rights poster is posted in the dining area.
Client Records-Incident Reports: Client files are kept in a locked cabinet and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.
Food Service: All clients in the facility are on a restricted enteral feeding diet and the facility has sufficient nutrients for the clients.
Health Related Service: Staff designated to administer medication has the proper training on file. Medication is centrally stored in a locked medical cabinet and refrigerated medication is stored in a locked refrigerator and inaccessible to other clients.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.

During todays visit LPA conducted 3 staff interviews and 0 client interviews as clients are nonverbal.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit.

Exit interview held and a copy of the report was provided to the Administrator Hazel Gatan.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023

LIC809 (FAS) - (06/04)

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