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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601809
Report Date: 08/16/2021
Date Signed: 08/16/2021 02:15:16 PM

Document Has Been Signed on 08/16/2021 02:15 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ELWYN NC - BABCOCKFACILITY NUMBER:
198601809
ADMINISTRATOR:SAMANTHA TODERFACILITY TYPE:
734
ADDRESS:5149 BABCOCK AVETELEPHONE:
(818) 287-5416
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY: 5CENSUS: 3DATE:
08/16/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Eivet Azizian LVNTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced case management visit in regard to a self reported incident that occurred on July, 21 2021. LPA met with LVN Eivet Azizian and explained the reason for the visit. LPA spoke to Administrator Samantha Toder via telephone who stated Eivet can sign in her place.

Between 1pm – 2pm, LPA conducted a physical plant, interviewed staff and reviewed and obtained copies of documents pertinent to the incident.

On that date, a family member of Resident 1 (R1) appeared to act unusual with staff and displayed unsafe behavior. The family member also allegedly appeared to be upset that they couldn’t provide R1 with a shoe lace, although possessing a shoe lace or string like object does not comply with R1s care plan. During that day and previous visits the family member had been informed by staff to comply with the care plan.

Going forward staff will continue to monitor R1 as required by care plan as well as document all unsafe behavior displayed by the family member. Staff have also been instructed to call the police if similar behavior occurs again from the family member.

No further action is required at this time. Exit interview conducted, copy of report issued and sent via email.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2021
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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