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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602217
Report Date: 07/11/2024
Date Signed: 07/11/2024 11:25:21 AM

Document Has Been Signed on 07/11/2024 11:25 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ELWYN CALIFORNIA - NOVARROFACILITY NUMBER:
198602217
ADMINISTRATOR/
DIRECTOR:
VERNON VAN RODRIGUEZFACILITY TYPE:
735
ADDRESS:1027 NOVARRO STTELEPHONE:
(626) 699-1889
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 4CENSUS: 4DATE:
07/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:08 AM
MET WITH:Melissa Munoz DSPTIME VISIT/
INSPECTION COMPLETED:
11:35 AM
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Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA was greeted by DSP worker Melissa Munoz at approximately 8:06 AM and explained the reason for the visit. Acting House Manager Julianna Barrera took over visit.

The facility is licensed for age range 18 through 59. 4 non-ambulatory and with delayed egress. The facility is serviced by San Gabriel Pomona Regional Center. The facility is a single-story house and located in a residential neighborhood area. The facility includes dining area, living room, kitchen, three (3) client bedrooms, one (1) activity room, four (4) common bathrooms, one (1) private bathroom in room #4 office, laundry room, medication room/extra food storage room and an attached garage.

LPA Gutierrez conducted a tour of the facility, reviewed records, and interviewed 1 staff, and 2 clients. The following were observed: Three (3) bedrooms have the required furniture such as bed frames, dressers, lamps, and chairs. Client beds have the required linen. Each bedroom has a smoke detector which were tested. There is a carbon monoxide detector located in the hallway and another in the living room area. The bathrooms were observed to be clean. The hot water was between 108.9 to 113.6 degrees which is within the required 105 - 120 degrees. There is a fire extinguisher in the living room and is fully charged. Sharps are locked in the kitchen and inaccessible to residents. Cleaning supplies and toxins are locked in outside cabinet and inaccessible to residents. First Aid kits were fully stocked with current manuals. There was a sufficient supply of 2 days perishable foods which included fruits and vegetables. Seven (7) days non-perishable foods were observed. The front and backyard are well maintained and there are no pools or large bodies of water. Passageways and exits are free of obstruction. Backyard has a front and back patio area and a shed which is a storage area for the facility.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2024
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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Document Has Been Signed on 07/11/2024 11:25 AM - It Cannot Be Edited


Created By: Christian Gutierrez On 07/11/2024 at 10:51 AM
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: 07/11/2024

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, the licensee did not comply with the section cited above Administrators file was not accessible during visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2024
Plan of Correction
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Administrator will email copy's of file to LPA by 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:Tony Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024


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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ELWYN CALIFORNIA - NOVARRO
FACILITY NUMBER: 198602217
VISIT DATE: 07/11/2024
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Four (4) staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Four (4) client files were reviewed and included physicians report, TB clearance, and individual program plan (IPP) report. Administrator file was not accessible during todays visit. Last fire/earthquake drill was conducted in June of 2024. Infectious control plan was reviewed. One (1) staff was interviewed. Four (4) out of (4) client medications were reviewed. Medications are centrally stored in medication room and locked MAR log is used. The facility currently has two clients with restricted health. Conditions. The facility has licensed nurse during AM and PM shift. The clients restricted health care plans are updated annually, and the restricted health condition plan are updated in clients fie and staff also received training regarding clients’ condition.

Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided to Juliana Barrera.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
LIC809 (FAS) - (06/04)
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