198601809-9-26-2024-29-AS-EMOY-D9GU9N-20240926152324

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601809
Report Date: 09/26/2024
Date Signed: 09/26/2024 03:24:55 PM

Document Has Been Signed on 09/26/2024 03:24 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ELWYN NC - BABCOCK		FACILITY NUMBER:	198601809
ADMINISTRATOR/ DIRECTOR:	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:	09/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Laurie Hernandez - Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:45 PM

NARRATIVE

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Licensing Program Analysts (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 9:30 a.m. Upon arrival, LPA Mosley was greeted by staff and called the administrator to inform them of the visit. The administrator arrived later during the visit. The LPA met with Eivet Azizian, LVN and Administrator Laurie Hernandez and explained the reason for the visit. 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.

KITCHEN: The LPA inspected the kitchen/food service area at 9:55 a.m. Knives and sharps were observed in a locked drawer. Kitchen appliances were in operable condition. The facility did not have a sufficient supply of perishable food posing a potential health and safety risk to persons in care. Administrator stated that they have a food delivery scheduled for later today.The facility had a sufficient amount of non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 110.8 degrees Fahrenheit at 9:56 a.m. Cleaning supplies are kept locked at all times under the sink and inescapable to clients in care.

COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 12:03 p.m., smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguishers were observed and fully charged on 03/29/2024. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 09/17/2024 and are conducted monthly to accommodate each shift. Activities were observed in the common areas.

Report Continued on LIC 809C...

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

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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Document Has Been Signed on 09/26/2024 03:24 PM - It Cannot Be Edited

Created By: Erica Mosley On 09/26/2024 at 02:25 PM

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: 09/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80076(a)(1)

Food Service

(a) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan -Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in not having a sufficient quantity of perishable food in the refrigerator which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/30/2024
	Plan of Correction
1 2 3 4	Administrator has purchased food and will have food delivered today and by the POC due date and send proof to CCLD. A receipt of purchased food along with a photo of the sufficient supply of food in the refrigerator.

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:

Kasandra Lopez

LICENSING EVALUATOR NAME:

Erica Mosley

LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELWYN NC - BABCOCK	FACILITY NUMBER: 198601809
	VISIT DATE: 09/26/2024

NARRATIVE

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Report Continued from LIC 809...

RESTROOMS: The two (2) resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The restrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured; the first restroom measured at 110.8 degrees Fahrenheit at 9:48 a.m. the second bathroom measured at 112.6 degrees Fahrenheit at 9:53 a.m. both restrooms within the required range.

BEDROOMS: There are 5 (five) total bedrooms in the facility. All five (5) are designated as a private resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

LAUNDRY ROOM: There is a washer and dryer on premises. Laundry detergent was observed in the washer and dryer area. Cleaning supplies are also kept in the laundry room. Laundry room is kept locked at all times and inaccessible to clients in care.

GARAGE/BACKYARD: LPA observed an adequate amount of emergency food and water. The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. LPA observed one (1) self-closing gate. There were no bodies of water noted at the time of the visit.

MEDICATIONS: Medications review began at approximately 11:55 a.m. The medications are kept in a locked cart located in the hallway. Medications for four (4) clients were reviewed. Medications reviewed were found to be self administered as prescribed and documented on the centrally stored medication and destruction records. No errors observed during the medication review.

Report Continued on LIC 809C...

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELWYN NC - BABCOCK	FACILITY NUMBER: 198601809
	VISIT DATE: 09/26/2024

NARRATIVE

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Report Continued from LIC 809...

RECORDS: The LPA and Administrator reviewed P&I money at 2:45 p.m. for three clients. Cash resources were found to be separate and intact and not commingled with facility funds or petty cash.

Resident Records were reviewed beginning at 10:26 a.m. and personnel records at 11:14 a.m. Four (4) client files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. Four (4) personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order.

INTERVIEWS: Three (3) staff interviews were conducted. Four (4) client interviews were attempted. No concerns noted.

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, Surety bond and a copy of the liability insurance.

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: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

LIC809 (FAS) - (06/04)

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