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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602917
Report Date: 01/28/2025
Date Signed: 01/29/2025 08:10:47 AM

Document Has Been Signed on 01/29/2025 08:10 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-RANCHO LINDOFACILITY NUMBER:
198602917
ADMINISTRATOR/
DIRECTOR:		VILLONDO, APRILFACILITY TYPE:
735
ADDRESS:527 S RANCHO LINDO DRIVETELEPHONE:
(626) 257-3201
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY: 4CENSUS: 4DATE:
01/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Osamede Oghide, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Daniel Konishi conducted the required annual inspection. LPA arrived unannounced and met with the administrator, Osamede Oghide that assisted with the visit. The facility is licensed for age range 18 through 59. Four (4) non-ambulatory. The facility is vendored by San Gabriel Pomona Regional Center. Facility currently has 4 clients.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and following were observed:

1. Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting at least once a day and more often for high touched surfaces. Facility has sufficient PPE supplies and has an Infection Control Plan in place.

2, Physical Plant: The facility is a single-story house and located at a residential neighborhood area. The facility includes: a kitchen, dining area, living room, four clients’ bedrooms, two bathrooms, staff office area, med room, laundry room and attached garage. Bedrooms have two beds, chairs, drawers, required furniture and bedding and sufficient lighting and closet space. Based on record review, clients with bed rails have appropriate physician’s order approval. The four clients’ bathrooms are clean, sanitary and in a good working condition. The hot water in two bathrooms were tested between 106.6 and 110.4 degrees F which are within the Title 22 regulation. The appliances in the kitchen and living room are all a working well. All the sharp knives are stored and locked in the kitchen drawer. The chemicals and all cleaning supplies are stored and locked underneath the sink in the kitchen and locked in the cabinet in the laundry room. The extra personal hygiene products are stored in the locked cabinet in the garage. The extra linens are stored in each client’s bedrooms. The carbon monoxide detector was tested and working properly. The facility has a land-line telephone system.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2025
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 5
Document Has Been Signed on 01/29/2025 08:10 AM - It Cannot Be Edited


Created By: Daniel Konishi On 01/28/2025 at 02:33 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: 01/28/2025

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, Administrator's file is missing training on HIV and TB which poses a potential health, safety or
personal rights risk to persons in care.
POC Due Date: 02/11/2025
Plan of Correction
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Administrator will send a copy of the HIV and TB training certificate to the LPA by the POC due date.
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
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Based on record review, Administrator's file is missing a health screening which poses a potential health, safety or
personal rights risk to persons in care.
POC Due Date: 02/11/2025
Plan of Correction
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Administrator will send a copy of the Administrator's health screening to the LPA by the POC due date.
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:Daniel Konishi
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2025


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 01/29/2025 08:10 AM - It Cannot Be Edited


Created By: Daniel Konishi On 01/28/2025 at 02:33 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: 01/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the Administrator did not comply with the section cited above and the Staff #5 (S5) did not have
valid first aid training in file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/11/2025
Plan of Correction
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Administrator will email Staff #5 (S5's) valid first aid 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:Daniel Konishi
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2025


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-RANCHO LINDO
FACILITY NUMBER: 198602917
VISIT DATE: 01/28/2025
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2, Physical Plant [Cont.]:

The hallway light would be on during nighttime so client can access to the non-private bathrooms. The passageway, walkway and patio are free of obstruction. The facility’s backyard area has shaded patio with table and two side exits with self-closing latches.

3.Operational Requirement: The facility was cleared for four (4) non-ambulatory. The last fire drill was conducted on 12/04/2024. The last earthquake drill was conducted on 12/11/2024. The clients can attend the community activities if there's an opportunity or chance. The facility does have a shaded patio with table and chairs for client to use as an outdoor activity.



4.Staffing: The facility has a total of thirteen (13) staff in the facility. LPA reviewed the NOC-Shift staff and the staff does have the required the facility planned emergency procedure training. The facility has at least one person on call.

5.Personnel Record-Training: Six (6) staff files were reviewed for criminal background clearance and training. All six (6) staff are associated with the facility. Personnel records have health/Tuberculosis (TB) screenings, employee rights, certifications, and 1st Aid/CPR training. However, Staff #5 (S5) did not have an updated First Aid training in file. Administrator’s Health Screening was not in file. Facility has per regulation staff training in file. The administrator is Osamede Oghide and administrator certificate expiration date on 11/15/2025. The Administrator did not have an updated HIV and TB training certificate in file.

6.Client Rights: Currently the facility has client with postural supports. The facility does provide internet service with at least one internet access device for client to use as communication with their family members or day program.

7.Clients Records-Incident Reports: The clients files are stored in the file cabinet in the staff office area. LPA inspected all four (4) clients files and they have all the required documents which include face sheet, emergency identification and information, admission agreement, immunization records, functional capabilities assessment, individual program plan (IPP), physician's report, TB test result, ambulatory status, client rights, physician's orders, safeguards for personal valuables, safeguards for cash resources, and medication list. LPA reviewed all clients' P & I.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
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-RANCHO LINDO
FACILITY NUMBER: 198602917
VISIT DATE: 01/28/2025
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8.Food Service: Currently two clients are on puree diet and the doctor's note is in client's files. The facility has sufficient 2 days perishable and 7 days non-perishable food supply in the facility. All the food are stored properly. LPA observed the kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

9.Health-Related Services: The client's medication is centrally stored and locked in the closet by the med room. LPA reviewed all four (4) client's medication and they are all seemed accurate and updated. First Aid Kit was reviewed and has required items. The facility also provide transportation for client's medical and dental appointments.

10. Incidental Medical Services: Currently the facility has clients on a restricted health condition plan and has sufficient staff training.

11. Disaster Preparedness: The facility has an updated emergency disaster plan with relocation sites, shutoff valves, and local emergency contact numbers. .

12, Emergency Intervention: The facility does not use any restraint on clients.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit are documented on the LIC809-D. Exit Interview conducted and a copy of the report with appeal rights were provided to the Administrator, Osamede Oghide.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
LIC809 (FAS) - (06/04)
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