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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602217
Report Date: 07/14/2023
Date Signed: 07/14/2023 05:04:32 PM

Document Has Been Signed on 07/14/2023 05:04 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 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:
07/14/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Estrella BarreraTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Wong conducted an Annual/Required visit by using the Compliance And Regulatory Enforcement (CARE) Tools on 7/11/2023 but due to time restrains and LPA Wong has returned on today's date 7/14/23 to finish the remaining three (3) domains. LPA met with House Manager Estrella Barrera who allowed entry into the facility and assisted with the visit.

On today's date, LPA inspected the three (3) domains include: Personnel Record-Training, Health Related Services and Disaster Preparedness.

1. Personnel Record-Training: All the staff files are stored and maintained in the facility staff office. All the staff are over 18 years old and they are all associated with the facility with criminal record clearance. The administrator is Martin Sy and his administrator certificate was already expired on 09/20/22 but it shown the application is pending now from CCL website but facility does have a back up administrator and her name is Estrella Barrera and the administrator certificate will be expired on 08/24/2024. The administrator did not have an updated HIV and TB training.

2. Health Related Services: The medication is centrally stored and locked in the medication cart in the storage room near the entrance. LPA inspected all four (4) clients medication and they are all updated and accurate. LPA also inspected the first aid kits and they all have required supplies in the kit.

3. Disaster Preparedness: The facility has an updated Emergency Disaster Plan (LIC610D) and its updated on 7/12/23 with emergency contact numbers and at least 2 temporary shelter relocation sites.

On today's visit, LPA interviewed one(1) staff and one (1) client and the others were not able to interview due to their unavailability.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 1

Exit interview was conducted, Appeals Rights discussed and a copy of the report was given to the House Manager Estrella Barrara



SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2023
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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Document Has Been Signed on 07/14/2023 05:04 PM - It Cannot Be Edited


Created By: Christine Wong On 07/14/2023 at 12:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ELWYN CALIFORNIA - NOVARRO
FACILITY NUMBER: 198602217

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(k)
Administrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA observed the administrator does not have the required HIV and TB training which posed a potential risk to clients in care
POC Due Date: 07/28/2023
Plan of Correction
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The administrator will send the HIV andTB training certificate to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:David Sicairos
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2023


LIC809 (FAS) - (06/04)
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