198602917-3-20-2023-28-AS-CDCN-CQ4VYK-20230320165117

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602917
Report Date: 03/20/2023
Date Signed: 03/20/2023 04:51:33 PM

Document Has Been Signed on 03/20/2023 04:51 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	ELWYN CALIFORNIA-RANCHO LINDO		FACILITY NUMBER:	198602917
ADMINISTRATOR:	VILLONDO, APRIL		FACILITY TYPE:	735
ADDRESS:	527 S RANCHO LINDO DRIVE		TELEPHONE:	(626) 257-3201
CITY:	COVINA	STATE: CA	ZIP CODE:	91724
CAPACITY: 4		CENSUS: 4	DATE:	03/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Lupita Garcia, House Manager		TIME COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tool. LPA arrived unannounced and met with the House Manager, Lupita Garcia. The purpose of the visit was explained. The facility is licensed for (4) non-ambulatory clients, ages 18 - 59. LPA toured the facility and conducted the following domains: Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting at least once during each shift and more often for high touched surfaces. Facility has sufficient PPE supplies and still screening for COVID-19 symptoms. LPA requested for the administrator to submit the Infection Control Plan within a week. Physical Plant & Environment Safety: The facility does not have any pool or bodies of water on the premises. There are 4 client bedrooms, 1 activity room, 1 full bathroom, 1/2 bathroom, medication room, laundry room, living room, dining room, kitchen, and attached garage. Each client bedroom has the required furniture. Extra hygiene supplies were observed. The dual smoke and carbon monoxide detectors are interconnected and operable. Knives, cleaning solutions, and disinfectants are locked, making them inaccessible to clients. There are no firearms or weapons stored at the facility. The hot water temperature were measured between the required range of 105-120 degrees F. Operational Requirements: The facility is licensed for (4) non-ambulatory adults ages 18 - 59. There are currently 4 clients residing at the home and were placed by the San Gabriel/Pomona Regional Center. Staffing: There is sufficient staffing at the facility, with (2) staff in the morning, (4) staff in the afternoon, and (2) in the overnight shift. Staff are fingerprint cleared and associated to the facility.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023

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-RANCHO LINDO	FACILITY NUMBER: 198602917
	VISIT DATE: 03/20/2023

NARRATIVE

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Personnel Records-Training: Staff files are maintained at the facility and LPA reviewed (4) personnel files. Administrator (April Villondo) certificate expires on 07/18/2024. Staff #2 did not have a health screening report nor TB test results on file.
Client Records - Incident Reports: Client files are maintained at the facility. LPA reviewed (4) client files and they have the required documentation.
Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. Freezer is maintained at a temperature of 0 degree F and the refrigerator at a maximum of 45 degrees F. Food items are properly stored.
Health-Related Services: The medications are centrally stored and locked. The facility uses the Medication Administration Record (MAR) log to document medications given. LPA reviewed medications for all 4 clients and they are being administered as prescribed by the physician.
Incidental Medical Services: There are 2 clients who have health conditions that need to be monitored more carefully and there is a facility LVN (Licensed Vocational Nurse) or LPT (Licensed Psychiatric Technician) on duty for each shift.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Staff are provided training on the emergency procedures and know where the utility shutoff valves are located. The client roster is posted and the clients' face sheet have been updated.
Emergency Intervention: Staff have CPI training. Their CPR/first aid certificates have not expired. The staff do not need to use manual restraint on the clients at this home and utilize de-escalation techniques.

There is a deficiency issued on the LIC809D. LPA provided a technical assistance for the Infection Control Plan and to document emergency drills at least every quarter.

An exit interview was held. A copy of this report, the LIC809D, and technical advisory notes were given to Staff Gabby Marroquin.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/20/2023 04:51 PM - It Cannot Be Edited

Created By: Cynthia D Chan On 03/20/2023 at 04:26 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-RANCHO LINDO	FACILITY NUMBER: 198602917
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80066(a)(10)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in which 1 out of 4 staff did not have the health screening form on file which poses a potential health and safety risk to persons in care.
	POC Due Date: 03/31/2023
	Plan of Correction
1 2 3 4	Administrator shall ensure all staff's health screening form is in their files. The health screening form for Staff #2 shall be provided to LPA by 3/31/23.

Type B

Section Cited

CCR

80066(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in which 1 out of 4 staff files did not have the TB test results which poses a potential health and safety risk to persons in care.
	POC Due Date: 03/31/2023
	Plan of Correction
1 2 3 4	Administrator shall ensure all staff have a TB test on record. The TB test result for Staff #2 shall be provided to LPA by POC due date 3/31/23.

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:

Cynthia D Chan

LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023

LIC809 (FAS) - (06/04)

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