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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601818
Report Date: 09/14/2022
Date Signed: 09/14/2022 02:27:01 PM

Document Has Been Signed on 09/14/2022 02:27 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ELWYN NC - SCENICFACILITY NUMBER:
198601818
ADMINISTRATOR:LAURIE HERNANDEZFACILITY TYPE:
734
ADDRESS:11526 SCENIC DRTELEPHONE:
(408) 558-1500
CITY:WHITTIERSTATE: CAZIP CODE:
90601
CAPACITY: 4CENSUS: 3DATE:
09/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Maureen Miranda (LVN)TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Kruz Long conducted a site visit for the annual inspection. Upon arriving at the facility LPA met with Maureen Miranda (LVN) who assisted with the visit. The facility is licensed to serve four (4) bedridden adults.

The facility is located in a residential area. A tour of the single-story facility includes: Living room, dining area, kitchen, 4 client bedrooms, laundry room, 1 full bathroom, 2 half bathrooms and an attached garage/storage.

During today's visit, LPA observed the following: Licensee is not operating beyond the conditions and limitations specified on the license, including the capacity. There are no firearms on the premises and other dangerous weapons such as knives are locked. Disinfectants, cleaning solutions, poisons are inaccessible to clients. A comfortable temperature for clients is maintained. All medications for clients are kept locked and inaccessible to other clients. The bathrooms are clean and operational. Clients bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The hot water temperature was tested and measured within Title 22 Regulation guidelines in the full bathroom. There is a land line located in the kitchen area. The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. All storage areas for cleaning solutions, toxins, and hazardous items are secured and inaccessible to clients. The last Fire/Emergency Drill was conducted on 09/08/22. LPA reviewed staff files and client medications. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguisher was observed to be fully charged. The first-aid kit is fully stocked with First-aid Manual. A shaded area with chairs is provided in the back yard. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction.

No deficiencies were observed during today's visit.
An exit interview was conducted and a copy of this report was provided to Maureen Miranda.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2022
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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