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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602217
Report Date: 08/24/2021
Date Signed: 08/24/2021 02:51:37 PM

Document Has Been Signed on 08/24/2021 02:51 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 CALIFORNIA - NOVARROFACILITY NUMBER:
198602217
ADMINISTRATOR:CESAR GOMEZFACILITY TYPE:
735
ADDRESS:1027 NOVARRO STTELEPHONE:
(626) 699-1889
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 4CENSUS: 4DATE:
08/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH: Nadia Gomez and Estela BarreraTIME COMPLETED:
03:00 PM
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On 08/24/21 at 10:00 AM, Licensing Program Analysts (LPA) Nune Margaryan and LPA Nina Galarza arrived at this facility unannounced to conduct an annual inspection visit. LPAs met with Estela Barrera and Nadia Gomez. Purpose of the visit was explained. LPAs conducted using the infection control domain tool.
LPAs inspected the physical plant including but not limited to the dining room, living room, activity room, office, resident's bedrooms (4); resident's bathrooms (3 common bathrooms, 1 private located in the bedroom), laundry room, kitchen, attached garage and outside areas of the facility to ensure compliance with Title 22 regulations.
Facility is licensed for 4 non ambulatory Developmentally Disabled clients between 18 and 59 years old serviced by San Gabriel regional Center.
Upon entry LPAs observed delay egress functioning properly.
The facility has one central entry point and has implemented screening and sign in procedures at the front of the home. LPAs observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted at the front door and throughout the facility. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 wing if needed. Common touch surfaces are cleaned after each use. All staff were observed to be wearing mask upon entrance and during visit.
The bathrooms were observed to be clean, operational and equipped with grab bars and non-skid mats. The hot water temperature was tested throughout the facility and measured between 111.1 and 112.8 degree F.
The kitchen was inspected. LPAs observed the kitchen equipment's to be clean and in working condition. LPAs observed the food supply stored at the facility. There was a sufficient quantity of the perishable for 2 days and non-perishable food supplies for 7 days for all clients. Cleaning chemicals, and knives are locked and inaccessible to clients. LPAs observed that fireplace in the living area is secured.


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SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2021
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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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 CALIFORNIA - NOVARRO
FACILITY NUMBER: 198602217
VISIT DATE: 08/24/2021
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LPAs observed the centrally stored medications area to be locked and inaccessible to clients. LPAs reviewed client medications records and stored medication. All medications were properly labeled and administered as directed by the physician.

The fire extinguishers observed to be fully charged. Smoke/carbon monoxide detectors were observed to be fully operational.

An outdoor shaded area is available in the backyard. There was no pool or bodies of standing water observed in the exterior of the facility property. Exits and passageways were free of obstructions.

Per the California Code of Regulations, Title 22 no deficiencies observed. Exit interview held, copy of report and appeal rights provided.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
LIC809 (FAS) - (06/04)
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