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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601818
Report Date: 11/19/2021
Date Signed: 11/19/2021 10:53:49 AM

Document Has Been Signed on 11/19/2021 10:53 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ELWYN NC - SCENICFACILITY NUMBER:
198601818
ADMINISTRATOR:NOHELY MACIASFACILITY TYPE:
734
ADDRESS:11526 SCENIC DRTELEPHONE:
(408) 558-1500
CITY:WHITTIERSTATE: CAZIP CODE:
90601
CAPACITY: 4CENSUS: 3DATE:
11/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Jasmine Oh, Registered NurseTIME COMPLETED:
11:05 AM
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Licensing Program Analyst (LPA) Vasallo conducted an Annual Required visit. LPA met with Registered Nurse (RN) Jasmine Oh who assisted with the visit. Administrator, Laurie Hernandez arrived a short time later. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, reviewed clients' medications, observed food supply, and reviewed client and staff files. Facility has submitted a mitigation plan and the plan has been approved.

The facility is currently caring for 4 clients and the approved capacity is 4. Oxygen tanks were observed to be secured on stands. Passageways are free of any obstructions. Each bedroom has a direct exit to the outside. The front and backyard are well maintained. The required back-up power supply is located in the garage. There are no pools or large bodies of water. Cleaning supplies and toxicants are inaccessible to clients. There is sufficient lighting throughout the facility. The client bedrooms have the required furniture including bedframes and dresser drawers and also have sufficient closet space. The lift system was tested in each bedroom and all were operating at the time of the visit. The client bathroom is clean and has the required equipment to meet the clients needs. The lift system in the bathroom was tested and was operating properly during the visit. The hot water temperature was 109.1 degrees, which is within the required range of 105-120 degrees.

The facility has medical professionals on shift and they are responsible for the gastronomy feeding and medication administration. During the visit there was a Registered Nurse (RN), a Licensed Vocational Nurse (LVN) and 2 Director Support Professionals (DSP). Staff files were reviewed. Staff have criminal record clearances. Medical professionals have current certificates on file. Staff have complete health screenings and proof of training. Staff have current first aid/CPR certificates. Client files were reviewed. Clients have complete needs and services plans, Individual Health Care Plans (IHCP), and current medical assessments. Facility documents the fire drills and earthquake drills as required. Facility also has a current log of the back-up generator testing. Medications were observed to be inaccessible to clients. Medications were reviewed and were observed to be documented properly and given as prescribed. Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held. A copy of the report was provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Tony Vasallo
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2021
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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