198601818-8-18-2023-28-AS-KRAZ-CUTTSU-20230818145940

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601818
Report Date: 08/18/2023
Date Signed: 08/18/2023 03:01:06 PM

Document Has Been Signed on 08/18/2023 03:01 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	ELWYN NC - SCENIC		FACILITY NUMBER:	198601818
ADMINISTRATOR:	LAURIE HERNANDEZ		FACILITY TYPE:	734
ADDRESS:	11526 SCENIC DR		TELEPHONE:	(408) 558-1500
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90601
CAPACITY: 4		CENSUS: 3	DATE:	08/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:26 AM
MET WITH:	Staff #1		TIME COMPLETED:	01:45 PM

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 08/18/2023 at 9:06 am. LPA was met by Staff #1 (S1) and explained the purpose of the visit. This facility is licensed as an Adult Residential Facility for Persons with Special Healthcare Needs (ARFPSHN) and is vendored by East Los Angeles Regional Center. The facility serves three (3) developmentally disabled clients ages 18 and above; of which four (4) may be bedridden. A total of eighteen (18) staff members provide care and supervision to the clients. LPA Ramirez requested and obtained copies of Personnel Report (LIC 500), and Client Roster (LIC 9020).

LPA OBSERVATIONS: Tour began at 9:17 am and was led by S1. The facility is a single-story home that contains four (4) bedrooms fully equipped with mechanical lifts, three (3) bathrooms of which two (2) are equipped with a mechanical lift, a living room, family room, kitchen, dining room, laundry room, backyard shaded patio area, and attached garage. LPA Ramirez observed one (1) Registered Nurse (RN), one (1) Licensed Vocational Nurse (LVN), and two (2) Direct Support Personnel (DSP) during visit. Fully charged fire extinguishers were observed throughout the facility.

Front Yard: Was clean and well maintained. No hazards were observed. Passageways are free of any obstructions.

SEE 809-C for continuation.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ELWYN NC - SCENIC	FACILITY NUMBER: 198601818
	VISIT DATE: 08/18/2023

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Kitchen: LPA Ramirez observed appliances to be clean and in working order. LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located kitchen cabinet, to be inaccessible to three (3) out of three (3) clients in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located in bottom kitchen cabinet to be inaccessible to three (3) out of three (3) clients in care. Water temperature was measured at 114. 0 degrees F. Signs promoting hand washing were observed in this area. Meal plan was observed in this area.

Dining Room/Living room: Dining room was observed to be clean and contained one table with plenty of seating. Living room was observed plenty of seating and lighting. LPA Ramirez observed board games and craft in this area. Activity calendar for the month of August 2023 was observed in this area.

Linen Closet: Contained plenty linens, towels, and hygiene products.

Client Rooms 1 - 4: LPA Ramirez observed all resident bedrooms to contain the required linens, furnishings, and lighting. LPA Ramirez observed mechanical lifts in all client bedrooms and were observed to be in working order. Client bedroom #4 is currently unoccupied.

Bathrooms: Water temperature in client bathroom#1 was measured at 114.8 degrees F. Client bathroom #2 water temperature was measured at 107.0 degrees F. Mechanical lift in bathroom# 2 was not operable. Per S1, mechanical lift was not functioning this morning and a work order was submitted prior to LPA Ramirez arriving to the facility. Client bathroom #3 water temperature was measured at 113.5 degrees F. Mechanical lift in bathroom #3 was observed to be operable. All client bathrooms were observed to be clean and signs promoting hand washing were observed.

Laundry Area: LPA Ramirez observed laundry soap and supplies to inaccessible to three (3) out of three (3) clients in care.

Centrally Stored Medications: LPA Ramirez medications cart to be locked and inaccessible to three (3) out of three (3) clients in care. Back up medications were observed to be locked and inaccessible in kitchen cabinet.

Backyard: No large bodies of water were observed. Passageways are free of any obstructions.

SEE 809-C for continuation.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ELWYN NC - SCENIC	FACILITY NUMBER: 198601818
	VISIT DATE: 08/18/2023

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Attached Garage: LPA Ramirez observed oxygen tanks to be secured on stands. Generator was observed and S1 provided documentation on bi-weekly testing of generator. LPA Ramirez observed emergency water, food and disaster supplies in garage.

Emergency Drills: Proof of last documented fire drill was conducted 8/8/23 during PM shift. Emergency drill was conducted on 7/24/23 during the AM shift.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide and smoke detectors in hallways. Smoke detectors were observed to be operable during visit.

Staff Personnel Files: Four (4) staff files were reviewed, and LPA Ramirez observed various in-house service trainings for the months of January 2023 through July 2023. Administrators Certificate for Laurie Hernandez with an expiration date of 7/26/24 was observed.

Client Files: Three (3) client files were reviewed.

No deficiencies were cited. Exit interview conducted with S1. A copy of this report was provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

LIC809 (FAS) - (06/04)

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