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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603013
Report Date: 04/10/2025
Date Signed: 04/10/2025 04:45:42 PM

Document Has Been Signed on 04/10/2025 04:45 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ELWYN CALIFORNIA--ORANGE GROVEFACILITY NUMBER:
198603013
ADMINISTRATOR/
DIRECTOR:		VILLONDO, APRILFACILITY TYPE:
735
ADDRESS:14420 ORANGE GROVE AVENUETELEPHONE:
(626) 269-0892
CITY:HACIENDA HEIGHTSSTATE: CAZIP CODE:
91745
CAPACITY: 4CENSUS: 4DATE:
04/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:20 PM
MET WITH:Dianne Vega, StaffTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Daniel Konishi and Gabriela Castro conducted the unannounced Annual Inspection visit using the Compliance And Regulatory Enforcement (CARE) Tool. LPA met with S1 and the purpose of the visit was discussed.

The following 9 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Client Rights/Information, Food Service, Health Related Services, Disaster Preparedness, and Emergency Intervention.

Infection Control: LPA observed the facility has sufficient PPE supplies. Infection Control Plan is in place. The plan was collected and reviewed.

Physical Plant and Environmental Safety: The facility is licensed to serve (4) clients of ages between 18-59. (1) AMBULATORY & (3) NON-AMBULATORY, OF WHICH 3 MAY BE BEDRIDDEN. Bedridden clearance for rooms #2-#4 There are currently (3) clients who were placed by the San Gabriel Pomona Regional Center. Facility is located in a residential area and consist of a living room, kitchen, dining area, office space, attached garage/laundry, 4 client bedrooms and 2 bathrooms. The facility was inspected during the physical plant tour. No passageways or paths were obstructed in Indoor and outdoor areas. Fire Extinguishers are fully charged and last inspected on 11/19/2024. Carbon Monoxide detectors were tested and working properly.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2025
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 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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--ORANGE GROVE
FACILITY NUMBER: 198603013
VISIT DATE: 04/10/2025
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Operational Requirements: Facility is operating within its approved clearance.

Staffing: The facility has a sufficient staffing in the facility. Facility is present during the Nightshift.

Client's Rights - Information: No client in the facility required any postural support at the present time. Required postings observed.

Food Service: The facility has sufficient food supplies of 2-day perishable and a week of non-perishable items. The food is properly stored in the refrigerator (clean and well-maintained). There are clients with special diets residing at this facility. Kitchen is kept clean. LPA observed the Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

Health Related Services: The medications are centrally stored and in their original containers. LPA reviewed medication for all four (4) clients. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubble packed and delivered monthly. Facility staff provide transportation to medical and dental appointments.

Disaster preparedness: The facility has an updated emergency disaster plan. The last fire/disaster drill was conducted on 7/10/24. Facility has client information readily available in case of emergencies.

Emergency Intervention: The facility are not using any restraints in the facility.

Due to time constraints, LPAs will return at a later date to complete 3 more CARE Tool domains. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies 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 S1.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/10/2025 04:45 PM - It Cannot Be Edited


Created By: Daniel Konishi On 04/10/2025 at 04:31 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--ORANGE GROVE
FACILITY NUMBER: 198603013

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill
shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation
of individuals served by the facility is not required during a drill. While a facility may provide an
opportunity for individuals served by the facility to participate in a drill, it shall not require that
participation. Documentation of the drills shall include the date, the type of emergency covered by
the drill, and, if applicable, the names of staff participating in the drill

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review,facility conduted last Fire/Earthquake drill on 7/10/2024 and not conducted quarterlywhich poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2025
Plan of Correction
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Administrator will conduct a Emergency fire/earthquake drill and send the log and report to the 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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Daniel Konishi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2025


LIC809 (FAS) - (06/04)
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