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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602217
Report Date: 08/12/2022
Date Signed: 08/12/2022 11:51:18 AM

Document Has Been Signed on 08/12/2022 11:51 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 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:
08/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:House Manager Estela BarreraTIME COMPLETED:
11:45 AM
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Licensing Program Analysts (LPA) Nune Margaryan conducted an annual required visit. LPA met with House Manager Estela Barrera and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. The physical plant was inspected along with COVID-19 procedures, medications, food supply, and resident and staff records. The facility has an approved mitigation plan on file. The facility is licensed to serve developmentally disable clients between the ages 18 to 59. There are currently 4 clients residing at the home and receive services from San Gabriel / Pomona regional Center.
LPA toured the home and inspected 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. The front and backyard are well maintained and there are no pools or large bodies of water. Passageways and exits are free of obstruction. There is a shaded seating area / patio for the clients. LPA observed fireplace in the living room which was secured with metal screen.

LPA observed laundry detergent, cleaning solutions/disinfectants are stored and locked in the laundry room. There is only one entrance being utilized at the facility, all required posters were posted at the entrance. There is a designated area in the living room where the log and PPE supplies are set up. LPA was screened upon entry. All staff were observed to be wearing mask upon entrance and during visit. Client bedrooms were checked. Each bedroom is equipped with the proper furnishings. The bathrooms were toured. Bathrooms are clean and have the required hygiene items. The hot water temperature was tested and was measured within Title 22 Regulation guidelines. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and working properly. Knives are locked in the kitchen cabinet under the sink and inaccessible to clients.

Continue 809C



SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 08/12/2022
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LPA observed the centrally stored medications area to be locked and inaccessible to clients. The first aid kit was observed and found to be in compliance with the Title 22 Regulations. The fire extinguishers observed to be fully charged. Smoke/carbon monoxide detectors were observed to be fully operational.

LPA reviewed client files to confirm emergency contacts have been updated. LPA confirmed staff working have fingerprint clearances. LPA reviewed clients medications. Medications are documented properly and given as prescribed.



No deficiency was observed during today's visit. Exit interview was conducted with the House Manager and a copy of report was provided.

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

DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022
LIC809 (FAS) - (06/04)
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