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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601809
Report Date: 10/24/2023
Date Signed: 10/24/2023 03:41:43 PM

Document Has Been Signed on 10/24/2023 03:41 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:HAZEL LAZAGA GATANFACILITY TYPE:
734
ADDRESS:5149 BABCOCK AVETELEPHONE:
(818) 287-5416
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY: 5CENSUS: 4DATE:
10/24/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Vernon Rodriguez - AdministratorTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced Annual Continuation Visit to the facility to continue the annual inspection visit initiated on 09/26/2023. On today’s visit, LPA Arroyo was accompanied by Department of Developmental Services (DDS) Nurse Consultant III, Arnold Franco. Upon arrival, LPA and DDS Nurse Consultant III met with House Manager, Faith Ndegwa and Administrator, Vernon Rodriguez and the reason for the visit was explained. Entrance interview conducted.

During today’s visit, at 10:55 a.m., the LPA 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.
The LPA also conducted a file review and interviewed seven (7) staff members during the inspection.

RECORDS: The LPA reviewed client records at approximately 11:05 a.m. and staff records at approximately 12:55 p.m.

Four (4) client records were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, consent form, and current needs and services plan. All files were in order at the time of the visit.

Eighteen (18) staff files were reviewed for, but not limited to, the following: personnel records, health screening, criminal record statements, and current first aid/cpr certification. All files were in order at the time of the visit.

The facility is vendored by the North Los Angeles County Regional Center (NLACRC).

Exit interview conducted. No deficiencies cited at this time. A copy of the report was issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2023
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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