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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601818
Report Date: 08/26/2024
Date Signed: 08/26/2024 12:08:16 PM

Document Has Been Signed on 08/26/2024 12:08 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/
DIRECTOR:		LAURIE HERNANDEZFACILITY TYPE:
734
ADDRESS:11526 SCENIC DRTELEPHONE:
(408) 558-1500
CITY:WHITTIERSTATE: CAZIP CODE:
90601
CAPACITY: 4CENSUS: 4DATE:
08/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Alex FuentesTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Jose Villalobos conducted the required unannounced annual inspection. LPA met with staff Alex Fuentes and informed the reason for the visit today. 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.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today. The following domains were completed:

Infection Control: Staff are using appropriate hand hygiene and wearing gloves when deemed necessary. Facility has an Infection Control Plan in place.

Operational Requirements: The fire clearance is approved for up to (4) bedridden clients. Facility has waivers in place for use of bed rails when clients are not on hospice as well as providing clients PRN medications without needing to contact clients physicians. Staff are adhering to operational requirements. Health and Safety Code Statutes adhered to as well. Emergency drills are being conducted as required. Last drill conducted on 6/8/24.

Physical Plant & Environment Safety: 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. There are no pools or bodies of water on the premises. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. There are no firearms or weapons stored at the facility. Water temperature measured within Title 22 regulations of 105-120 degrees.

Continued on LIC 809-C
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 - SCENIC
FACILITY NUMBER: 198601818
VISIT DATE: 08/26/2024
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Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed four (4) staff files. All staff files have current First Aid/CPR certification, Health Screening, Fingerprint clearances, and Criminal record statements on file. Staff receive on-going training on a monthly basis. Training log reviewed. Administrator file reviewed.

Client Records-Incident Reports: LPA reviewed all four (4) Client files. Files are centrally stored and they have the required documentation such as Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent forms, Individual Program Plan/IPP, Client Rights, Property Valuable and Cash resources forms.

Client Rights-Information: Clients are informed of their personal rights. Internet services are provided and clients have personal tablets.

Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. Special Diet modification observed. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: The medications are centrally stored. LPA reviewed medications for all four (4) Clients in care. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Plans are in place for providing care to client who rely upon others to perform all activities of daily living.

Disaster Preparedness: The facility has the current Emergency Disaster Plan in place.

There are no deficiencies issued today. An exit interview was held and a copy of this report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024
LIC809 (FAS) - (06/04)
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