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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601603
Report Date: 01/24/2025
Date Signed: 01/24/2025 04:14:58 PM

Document Has Been Signed on 01/24/2025 04:14 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ELWYN NC - LOS LOTESFACILITY NUMBER:
198601603
ADMINISTRATOR/
DIRECTOR:		LAURIE HERNANDEZFACILITY TYPE:
734
ADDRESS:15041 LOS LOTES AVETELEPHONE:
(562) 360-1225
CITY:WHITTIERSTATE: CAZIP CODE:
90605
CAPACITY: 5CENSUS: 5DATE:
01/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Rose Rivas, RN House ManagerTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Daniel Konishi conducted the required annual inspection. LPA arrived unannounced and met with S1 allowed the entry of the facility and assisted with the visit. The purpose for the visit was explained. The facility is licensed for Age Range 18 years and above. Five may be bedridden. The facility is ventured with East Los Angeles Regional Center. There are currently 5 (five) clients in the facility.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and only inspected those domain:



1. Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting at least once a day and more often for high touched surfaces. Facility has sufficient PPE supplies and has an Infection Control Plan.

2. Physical Plant and Environmental Safety: The facility is a single-story house and located in a residential neighborhood area. The facility includes: Living room, dining area, kitchen, open staff office, five clients’ bedrooms, two bathrooms, laundry room, and an attached garage. Each client bedroom has one bed, one chair, one drawer, lamps, required furniture and beddings and sufficient lighting and closet space. All clients with bedrails had physician’s orders in file. The two client bathrooms are clean, sanitary and in a good working condition. The hot water in clients’ bathroom #1 was read at 111.0 degrees F and bathroom #2 read at 112.4 degrees F which is within Title 22 regulations. All the knives and sharp utensils are stored and locked in kitchen drawer. All the cleaning supplies and chemicals are stored and locked underneath the kitchen sink and laundry room in a cabinet and inaccessible to clients. The extra personal hygiene products are stored and locked in the hallway cabinet and inaccessible to clients. The extra linen and towels are stored in the laundry room. Fireplaces and open-faced heaters are securely closed and inaccessible to clients. The facility has the hallway lights. The facility has a land-line telephone system. Fire extinguishers were observed in the kitchen, hallway, and garage and all are fully charged and last reviewed 09/25/2024.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ELWYN NC - LOS LOTES
FACILITY NUMBER: 198601603
VISIT DATE: 01/24/2025
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LPA inspected the carbon monoxide detectors and they are working properly. The walkway, passageway and patio are free of obstruction. Backyard have a shaded area for clients for outdoor activity.

3. Operational Requirement: The fire clearance is approved for age range 18 years and above. 5 may be bedridden. The last fire drill was conducted on 01/08/2025. The last earthquake drill was conducted on 12/11/2024. The facility has a patio with a shaded area with table and chairs for client to utilize for outdoor activity.



4. Personnel Records-Training: All the staff in the facility are over 18 years old, fingerprint cleared and associated with the facility. The administrator of the facility is Laurie Hernandez and she has all the requirement or prior experience to become an administrator of the facility. Administrator Expiration Date: 07/26/2026. Administrator has updated HIV and TB training certificate in file. All the staff files have the required documents in their files which is included criminal background clearance, personnel record, updated health screening, TB test result, employee application, employee rights, and required training hours and updated first aid/CPR certificate, and annual staff training..

5. Client Records-Incident Reports: LPA reviewed all five (5) clients files and they all have the required documents include face sheet, physician report, TB test result, ambulatory status, individual program plan (IPP), admission agreement, immunization record, functional capabilities assessment, Appraisal/Needs and Services Plan, Personal Rights, weight records, medication list, Safeguards for Personal Valuables, Safeguards for Cash Resource, and centrally stored medication destruction record. LPA reviewed client’s P & I.

6. Client's Rights-Information: Currently the facility does have postural support clients. The facility does serve adults with telephone and internet access.

7. Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food and sufficient supply of formula for the clients. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. Cleaning supplies and pesticides are stored away from food supplies. Currently, facility has clients that are on a modified diet that prescribed by a physician.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ELWYN NC - LOS LOTES
FACILITY NUMBER: 198601603
VISIT DATE: 01/24/2025
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8. Health Related Services: The client's medication are stored and locked in the medication cart. LPA inspected all five (5) clients medications and they are seemed updated and accurate and they all have a sufficient supply of mediations. Facility staff would provide transportation for client's medical and dental appointments.

9. Disaster Preparedness: The facility has an emergency disaster plan in place. The last fire drill was conducted on 01/08/2025. The last earthquake drill was conducted on 12/11/2024. The facility has two alternative shelter locations.

Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies were observed during the visit. Exit interview held and a copy of the report was provided to the S1.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
LIC809 (FAS) - (06/04)
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