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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602217
Report Date: 07/11/2023
Date Signed: 07/12/2023 08:37:30 AM

Document Has Been Signed on 07/12/2023 08:37 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ELWYN CALIFORNIA - NOVARROFACILITY NUMBER:
198602217
ADMINISTRATOR:VERNON VAN RODRIGUEZFACILITY TYPE:
735
ADDRESS:1027 NOVARRO STTELEPHONE:
(626) 699-1889
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 4CENSUS: 4DATE:
07/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Martin SyTIME COMPLETED:
04:50 PM
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Licensing Program Analyst (LPA) Wong conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with House Manager Estella Barrera and explained the reason of the visit and assisted with the visit. Shortly after, the administrator Martin Sy arrived and assisted with the visit too. The facility is licensed for age range 18 through 59. 4 non-ambulatory and with delayed egress. The facility is licensed as a level 4I vendored by San Gabriel Pomona Regional Center.

The following 9 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Client Rights/Information, Client Records/Incident Reports and Food Service,

1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility still encourages hand washing and self symptom check of staff and visitors. Each resident bedroom is designated as a COVID-19 isolation room if needed. The facility has an Infection Control Plan and COVID-19 mitigation plan.

2. Physical Plant/Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes: dining area, living room, kitchen, four clients bedrooms, four clients bathrooms, office, laundry room, medication room/extra food storage room and an attached garage. Each client bedroom has one bed, one night stand, one dresser, one chair, required beddings and furniture and sufficient lighting and closet space. The client's bathrooms are clean, sanitary and in a good working condition. The hot water temperature tested in all four bathrooms were 106.5 to 107.2 degrees F which is within the Title 22 regulation. The passage way, walkway and patio are free of obstruction. There's extra linen stored in the hallway storage room near the bathroom#2 and extra personal hygiene products are stored in the back yard storage room. The facility has hallway light and its stay on all day. The facility also has telephone services in the premises. (See LIC809C for continuation)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2023
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 CALIFORNIA - NOVARRO
FACILITY NUMBER: 198602217
VISIT DATE: 07/11/2023
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The sharp knives and utensils are stored and locked under the sink. All the cleaning supplies and chemicals are stored in the locked laundry cabinet and backyard storage room which is inaccessible to clients.

3. Operational Requirement: The facility is licensed for 4 non-ambulatory clients. Currently all four clients are ambulatory. The last fire drill was conducted on May, 2023 and last earthquake drill was conducted on June, 2023. The facility has a backyard patio with table and chairs for client to utilize. Client are allowed to attend or participate community activities if they want to.

4. Client Records-Incident Reports: All clients files are maintained in the facility and they all have the required documents included face sheet, admission agreement, physician report, ambulatory status, current medication list...etc

6. Client's Rights-Information: The facility does not have any client required postural support. The facility does serve adults has internet service shall provide at least one access device.

7. Food Services: Facility has sufficient food supply is stored in the kitchen and the storage room consisting of: 2-day perishables, 7-day non-perishables. Physician order for modified diet is on file. The refrigerator is maintained in the required temperature. All the food are stored probably.

8. Staffing: There's sufficient staffing in the facility. Three staff in AM and PM shift and two staff in NOC shift. The night supervision staff also does have the required training for the planned emergency procedure.

9. Incidental Medical Services: The facility currently has two clients with restricted health condition. The facility has licensed nurse during AM shift and PM shift. The clients' restricted health care plan are updated annually and the restricted health condition plan are updated in clients' file and staff also received training regarding clients' condition.

Due to time restrains, LPA was not able to complete the annual inspection by using the CARE tools. LPA will come back another time to finish the following domain which include: Personnel Records-Training, Health Related Services, Disaster Preparedness and Emergency intervention.

No deficiencies were observed during today's visit.

Exit interview was conducted, a copy of the report was given to the administrator Martin Sy
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
LIC809 (FAS) - (06/04)
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