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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601510
Report Date: 04/14/2022
Date Signed: 04/14/2022 12:17:43 PM

Document Has Been Signed on 04/14/2022 12:17 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:
04/14/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Jon O'CampoTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst, LPA Angelica Rea, while conducting visit to issue final report for Complaint #28-AS-20210709144103, was informed that the facility is currently under quarantine due to 3 Covid positive residents and 3 Covid positive staff. House Manager, Jon O'Campo stated that the he thought that it had been reported to Community Care Licensing, but was not sure. House manager stated that the first positive case was on 4/05/22. LPA Rea did not observe that it had been reported to Community Care Licensing. LPA Rea spoke to Administrator, Cesar Gomez to ask if it had been reported as required. Mr. Gomez stated that the House Manager should have reported the covid positive cases. LPA advised Mr. Gomez that a citation would be issued for Non- reporting requirements. LPA advised that the covid positive cases must be reported today.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2022
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 04/14/2022 12:17 PM - It Cannot Be Edited


Created By: Angelica Rea On 04/14/2022 at 11:44 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 NC - DOREEN
FACILITY NUMBER: 198601510

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/22/2022
Section Cited
CCR
80061(a)(1)(E)

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Each licensee or applicant shall furnish to the licensing agency reports as required by the Department, including, but not limited to, those specified in this section. Events reported shall include the following:
Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.

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Administration staff agreed to retrain all staff on reporting requirements, and ensure all COVID-19 cases are reported to CCLD, and other required agencies.

Submit a COVID-19 reporting Plan, as well as incident reports of all prior COVID-19 confirmed cases ny POC due date.
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House Manager, Jon O'campo and Administrator, Cesar Gomez stated that 3 Covid positive residents and 3 covid positive statff had not been reported to Community Care Licensing as required. This poses a health and safety risk to residents in care.
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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:Angelica Rea
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022


LIC809 (FAS) - (06/04)
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