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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603013
Report Date: 04/07/2022
Date Signed: 04/07/2022 03:53:45 PM

Document Has Been Signed on 04/07/2022 03:53 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ELWYN CALIFORNIA--ORANGE GROVEFACILITY NUMBER:
198603013
ADMINISTRATOR:VILLONDO, APRILFACILITY TYPE:
735
ADDRESS:14420 ORANGE GROVE AVENUETELEPHONE:
(626) 269-0892
CITY:HACIENDA HEIGHTSSTATE: CAZIP CODE:
91745
CAPACITY: 4CENSUS: 4DATE:
04/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Sprya MendozaTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Christine Wong conducted an unannounced annual required visit. LPA met with LVN Spyra Mendoza and explained the reason for the visit and she also assisted LPA with the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed clients' medications, observed food supply, and reviewed clients files. Facility has submitted a mitigation plan and was approved on 04/18/2021

The facility is a single story house and located in a residential neighborhood area. The facility included a living room, dining area, staff office, kitchen, four clients rooms, two clients bathrooms, medication area and an attached garage. All 4 clients bedrooms were toured. Each bedroom has a smoke detector, one bed, one chair, one dresser, one night stand, required linen, sufficient lighting and closet space. All 2 bathrooms were toured and they are clean and sanitary. The hot water was measured at two bathrooms are between 114.8 and 116.7 degrees F which is within Title 22 regulation. The food supply in the refrigerator and kitchen cabinet are sufficient for two days perishable and seven days non-perishable. All the appliances are clean and working properly. The common areas such as living room and dining area are clean and have the required furniture. The exit and passage ways are free of obstruction. The front and back yard are maintained well and the back yard has a shaded area with tables and chairs for client to utilize. The cleaning supplies are stored and locked in the kitchen cabinet. The knives and sharp utensils are locked and stored in the kitchen cabinet and its inaccessible to clients. The medication are centrally stored and locked in the medication cabinet in the medication area. LPA also reviewed all clients medications and they are all accurate and current. And all clients' emergency contact information are current and up-to dated. LPA also inspected the smoke detectors and carbon monoxide detectors and they are interconnected and working properly.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ELWYN CALIFORNIA--ORANGE GROVE
FACILITY NUMBER: 198603013
VISIT DATE: 04/07/2022
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Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, disinfecting products are available in the common area and facility is disinfected every shift and before use an after use. The bathrooms and the garage have sufficient soap, paper towels, and signs. PPE supplies are sufficient for more than 30 days.

No deficiencies were found during this visit. Exit interview was conducted with LVN Spyra Mendoza and a copy of this report was provided.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC809 (FAS) - (06/04)
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