198601809-9-23-2022-29-AS-ECAS-CJJTME-20220923145100

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601809
Report Date: 09/23/2022
Date Signed: 09/23/2022 02:52:08 PM

Document Has Been Signed on 09/23/2022 02:52 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 - BABCOCK		FACILITY NUMBER:	198601809
ADMINISTRATOR:	HAZEL LAZAGA GATAN		FACILITY TYPE:	734
ADDRESS:	5149 BABCOCK AVE		TELEPHONE:	(818) 287-5416
CITY:	VALLEY VILLAGE	STATE: CA	ZIP CODE:	91607
CAPACITY: 5		CENSUS: 4	DATE:	09/23/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Alexis Calicdan-LVN		TIME COMPLETED:	02:55 PM

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Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a required Annual visit. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Licensed Vocational Nurse (LVN) Alexis Calicdan whom contacted the Administrator over the phone and explained the reason for the visit. The Administrator was not present and authorized Alexis Calicdan to sign the report.

The LPA toured the physical plant areas inside and outside, with Staff at 10:30 a.m., to ensure there are no health and safety hazards.

BEDROOMS: There are five (5) bedrooms designated for resident use and one (1) open room designated for staff use, staff room is used for staff breaks. The facility has furnished each room with clean linens, appropriate furnishings, and sufficient lighting for resident use. All resident rooms are private. BATHROOMSThe facility has one (1) large resident bathroom and one (1) staff/visitor bathroom. Bathrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap and paper products. Bathroom hot water measured at 118.0 and 117.5 degrees Fahrenheit between 10:40 a.m. and 10:49 a.m. KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Knives, medications, and chemicals were locked and inaccessible. COMMON SPACES: The common spaces included the living room and dining area. All areas were clean, sanitary and in good repair. Smoke detectors are hardwired and interconnected. The fire extinguisher was observed to be full and last serviced on 3/11/2022. The LPA observed required postings on the wall at the entrance. Flooring was checked for cleanliness and appeared in good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELWYN NC - BABCOCK	FACILITY NUMBER: 198601809
	VISIT DATE: 09/23/2022

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BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. There were no accessible bodies of water noted. The LPA observed a small storage room attached to the garage containing additional supplies, emergency food, water and personal protective equipment (PPE). INFECTION CONTROL: Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. There was an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time. The LPA reminded the Administrator that masking protocols and temperature checks are still in place including vaccination requirements, visitation, and testing protocols.

No deficiencies were noted at this time. Exit interview conducted. A copy of this report discussed and provided via email to the Administrator, designated staff signature on this form confirm receipt of these documents.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022

LIC809 (FAS) - (06/04)

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