198601809-9-26-2023-29-AS-MARO-CW2PJV-20230926112211

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601809
Report Date: 09/26/2023
Date Signed: 09/26/2023 11:22:17 AM

Document Has Been Signed on 09/26/2023 11:22 AM - 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:	09/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Faith Ndegwa - House Manager		TIME COMPLETED:	11:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced for a required one-year annual inspection today at 8:30 a.m. The last annual conducted at this facility was on 09/23/2022. When the LPA arrived, there were four staff and three residents present. The LPA was scanned and greeted at the door by staff Kenneth Brooks. The House Manager, Faith Ndegwa arrived at 9:20 a.m. and at this time the reason for the visit was explained. The Administrator Vernon Rodriguez arrived during the inspection. Entrance interview conducted.

At 9:22 a.m., the LPA along with the House Manager, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: The LPA inspected the kitchen/food service area at 9:30 a.m. At 9:32 a.m., the hot water temperature was measured in the kitchen at 123.6 degrees Fahrenheit. Kitchen appliances appeared clean and were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Food labels were inspected and checked for dates and expiration dates and food labels had expiration date clearly marked. The LPA observed knives and sharps locked in a drawer.

COMMON AREAS: Living room and dining room furniture was observed to be in good condition. All common areas were clean, sanitary and in good repair. The facility maintained a comfortable temperature at 73 degrees Fahrenheit. Smoke detector(s) and carbon monoxide detector are hard-wired and were operational at the time of the visit. The fire extinguishers were observed fully charged and last serviced 03/27/2023. The LPA observed required postings throughout the common space. There is a functioning telephone on the premises. There is a separate laundry room, which is kept locked at tall times. Cleaning supplies and detergents were observed locked and inaccessible inside the laundry room. The last emergency disaster drill was conducted on 09/15/2023.

(Report Continued on LIC 809C...)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

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: 09/26/2023

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(Report Continued from LIC 809...)

GARAGE/BACKYARD: The LPA observed a sufficient supply of emergency food and water. The facility has at least a 30-day supply of Personal Protection Equipment (PPE). The backyard has a covered outdoor area equipped with furniture for client use. The facility has one (1) side gate that self-closes. Passageways were observed clear and free of obstructions in case of an emergency. No bodies of water noted at the time of the visit.

BEDROOMS: There are five (5) private client bedrooms. The LPA observed the client bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There is no staff room on premises. The facility has 24-hour wake staff. The LPA observed a sufficient supply of extra towels and linens.

RESTROOMS: There are two (2) restrooms on premises. One (1) restroom is for staff use and one (1) restroom which includes a shower is for client use. The restrooms were clean and sanitary and in operating condition with non-skid surfaces. The restrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. The hot water temperature was measured in the client bathroom, and it measured at 124.3 degrees Fahrenheit at 9:27 a.m. The Administrator had the hot water temperature adjusted at the time of the visit.

MEDICATIONS: Medications review began at 9:45 a.m.; medications are centrally stored and locked in a cart by the main hallway. All medications are labeled and maintained in compliance with label instructions, and state and federal law. Medications are labeled and checked for expiration dates. No errors observed during the medication review.

This facility is vendored by the Northern Los Angeles County Regional Center.

During today’s inspection, the LPA obtained the following documents: LIC500 Personnel Report, LIC9020 Client Roster, and a copy of the liability insurance.

Due to time constraints the LPA will return to complete the annual at a later date.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/26/2023 11:22 AM - It Cannot Be Edited

Created By: Martha Arroyo On 09/26/2023 at 10:46 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELWYN NC - BABCOCK	FACILITY NUMBER: 198601809
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above as two (2) our of three (3) faucets delivered water between 123.6 and 124.3 degrees Fahrenheit, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 09/26/2023
	Plan of Correction
1 2 3 4	The Administrator had the hot water temperature adjusted at the time of the visiit. POC has been met.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Desaree Perera

LICENSING EVALUATOR NAME:

Martha Arroyo

LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC809 (FAS) - (06/04)

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