<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601603
Report Date: 12/19/2025
Date Signed: 12/19/2025 04:32:39 PM

Document Has Been Signed on 12/19/2025 04:32 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:
12/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Edward Valarde-LVNTIME VISIT/
INSPECTION COMPLETED:
04:15 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) Kimberly Ramirez conducted an unannounced Annual Required Visit on 12/18/2023 at 11:34 am. LPA was met by Licensed Vocational Nurse (LVN)- Edward Velarde and explained the purpose of the visit. This facility is licensed as an Adult Residential Facility for Persons with Special Healthcare Needs (ARFPSHN) and is vendored by East Los Angeles Regional Center. The facility is licensed to serve five (5) developmentally disabled clients ages 18 and above; of which five (5) may be bedridden. During today’s visit, LPA Ramirez observed four (4) staff providing direct care and supervision to clients in care. LPA Ramirez requested and obtained copies of personnel report, and client roster.

LPA OBSERVATIONS: The facility is a single-story home that contains five (5) bedrooms fully equipped with electrical mechanical lifts, two (2) bathrooms of which one (1) is equipped with an electronical mechanical lift and shower gurney, living room, kitchen, dining room, laundry room, backyard shaded patio area, and attached garage. LPA Ramirez observed one (1) Registered Nurse (RN), one (1) Licensed Vocational Nurse (LVN), and two (2) Direct Support Professionals (DSP) during visit. Fully charged fire extinguishers were observed throughout the facility.

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

Physical Plant & Environmental Safety: Each client bedroom has one bed, one chair, dresser, lamps, bedding/linen and sufficient lighting and closet space. All client bathrooms were observed to be clean and signs promoting hand washing were observed. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees. LPA Ramirez observed shower gurney in gurney. Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to clients. LPA Ramirez observed carbon Extra personal hygiene products are stored and locked in the hallway cabinet and inaccessible to clients. 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 a land-line telephone system. SEE 809-C for continued report

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2025
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
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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: 12/19/2025
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
26
27
28
29
30
31
32
Operational Requirements: The fire clearance is approved for ages 18 years and older, of which five (5) may be bedridden. The last two emergency drills were conducted on 11/15/2025 and 10/21/2025. The facility has a shaded patio area with chairs and tables for clients to utilize.

Personnel Records Training: Staff in the facility are over 18 years old, fingerprint cleared and associated with the facility. The acting administrator of the facility is Rose Rivas and her Administrator’s Certificate expires on 10/14/2026 (certificate number- 6067181735). Staff files are maintained at the facility. LPA Ramirez observed training, CPR and First Aid for four (4) out of the four (4) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for four (4) out of the four (4) personnel record reviewed.

Clients 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.

Client Rights-Information: LPA Ramirez observed original admissions agreements in client records. LPA Ramirez observed Individual Program Plan (IPP), Needs and Services and Functional Capabilities Assessment. LPA Ramirez observed current medication record orders and incident reports regarding clients’ health and safety.

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 is prescribed by a physician.

Health-Related Services: The client's medication are stored and locked in the medication cart. Facility staff would provide transportation for clients’ medical and dental appointments.

Disaster Preparedness: The facility has an emergency disaster plan in place. Staff interviewed were able to physically locate areas of gas shut off and water shut off valves. The facility has two alternative shelter locations.

No deficiencies were observed during this annual inspection. Exit interview was conducted. A copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025
LIC809 (FAS) - (06/04)
Page: 3 of 3