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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601809
Report Date: 12/06/2024
Date Signed: 12/06/2024 04:43:32 PM

Document Has Been Signed on 12/06/2024 04:43 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 - BABCOCKFACILITY NUMBER:
198601809
ADMINISTRATOR/
DIRECTOR:		LAURIE HERNANDEZFACILITY TYPE:
734
ADDRESS:5149 BABCOCK AVETELEPHONE:
(818) 287-5416
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY: 5CENSUS: 2DATE:
12/06/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Jon O’ Campo - Home RN TIME VISIT/
INSPECTION COMPLETED:
04:50 PM
NARRATIVE
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At approximately 10:15 a.m. Licensing Program Analyst (LPA) Erica Mosley conducted a joint visit with North Los Angeles County Regional Center (NLACRC), Quality Assurance Specialist (QAS) Lisseth Carrillo on a Case Management - Deficiencies visit due to deficiencies observed during a complaint investigation of complaint control number 29-AS-20241204172138. The LPA and QAS advised the staff of the reason for the visit.
During the physical plant tour at 10:42 a.m. LPA observed the medication cart to be unlocked along with the keys left on top of the cart. The staff was informed and immediately locked the cart and removed the keys. Staff was made aware of the potential health and safety risk to clients in care. During the physical plant tour at 10:51 a.m. LPA observed a cabinet in the kitchen where chemicals are stored to be unlocked causing a potential health and safety risk to clients in care. Staff informed LPA that they are in the process of getting the lock replaced as it does not lock automatically as intended. Staff must manually lock the cabinet to ensure it is locked. At the time of the visit staff manually locked the cabinet to ensure the safety of clients in care. During the visit LPA observed a Clorox cleaning solution in the bathroom cabinet accessible to clients in care posing a potential health and safety risk to clients in care. At the time of the visit staff immediately locked the cleaning solution in the locked kitchen cabinet. Staff was informed about the importance of keeping cleaning solutions locked and inaccessible to clients in care.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8 and California Health and Safety Code the following deficiencies were observed and cited during the visit (See 9099-D).

Exit interview conducted. Report was reviewed. A copy and appeal rights were issued.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2024
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 12/06/2024 04:43 PM - It Cannot Be Edited


Created By: Erica Mosley On 12/06/2024 at 03:53 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: 12/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/20/2024
Section Cited
CCR
82075(L)(1)

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(l) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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Administrator will review with all staff the procedures that apply to medications which are centrally stored and send proof to CCLD that staff have reviewed the procedures by POC due date.
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Based on observation the licensee did not comply... medication cart was left unlock with keys on top of the cart.
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Type B
12/20/2024
Section Cited
CCR82087(a)(3)(A)

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(a) The program site shall be clean, safe, ... for the safety and well-being of clients, ... (3) Disinfectants, cleaning solutions, poisons, and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
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Administrator will review with all staff the procedures for properly storing chemical and get lock fixed in kitchen cabinet and send proof to CCLD by POC due date.
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(A) Storage areas for poisons shall be locked. Based on observation the licensee did not comply... kitchen cabinet... chemicals are stored and Clorox in bathroom were unlocked causing a potential health and safety risk to clients in care.
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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: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2024


LIC809 (FAS) - (06/04)
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