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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603150
Report Date: 04/16/2024
Date Signed: 04/16/2024 02:59:37 PM

Document Has Been Signed on 04/16/2024 02:59 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:ELMGROVE HOMEFACILITY NUMBER:
198603150
ADMINISTRATOR/
DIRECTOR:		DIXON, PAMELAFACILITY TYPE:
735
ADDRESS:2253 ELMGROVE STTELEPHONE:
(213) 361-2792
CITY:LOS ANGELESSTATE: CAZIP CODE:
90031
CAPACITY: 4CENSUS: 4DATE:
04/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Isaac Oluoch - AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:10 PM
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Licensing Program Analysts (LPAs) Jose Villalobos conducted the unannounced Annual Inspection visit using the Compliance And Regulatory Enforcement (CARE) Tool. LPA met with Administrator Isaac Oluoch and the purpose of the visit was discussed. The following tool domains were completed:

Infection Control: LPA observed the facility has sufficient PPE supplies. Infection Control Plan was collected and reviewed.

Physical Plant and Environmental Safety: The facility is licensed to serve 4 developmentally disabled adults ages 18 to 59 years old, of which (2) can be non-ambulatory. There are currently 4 clients who were placed by the Lanterman Regional Center. Facility is located in a residential area and consist of (4) client bedrooms, 2 bathrooms, living room, kitchen, and dining area. The facility was inspected during the physical plant tour. No passageways or paths were obstructed.

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.

Personnel Records-Training: Personal records centrally stored. LPA inspected four (4) staff files. All staff are background check cleared and associated with the facility. All the staff files have the required Title 22 documents. The administrators certificate is currently pending renewal.

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

Continued on LIC 809-C
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2024
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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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: ELMGROVE HOME
FACILITY NUMBER: 198603150
VISIT DATE: 04/16/2024
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Food Service: Supply of Non perishables and perishables was observed. Food supply was adequately stored. Pesticides and other toxic substances were not stored with the food supply. Kitchen area was clean.

Client Records/Incident Reports: Client files are centrally stored. LPA reviewed four (4) client files. Client files are up to date and have required documents.

Health Related Services: Medication is centrally stored and locked making them inaccessible to clients in care. LPA reviewed four (4) Client Medications. LPA did not observe any medication mismanagement.

Incidental Medical Services: No client in the facility has any restricted health condition plan. There are no clients in care with prohibited or restricted health conditions. First Aid kid observed and available when needed.

Disaster preparedness: The facility has an updated emergency disaster plan. The last fire/disaster drill was conducted on 12/11/23. Facility has client information readily available in case of emergencies.

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

Per Title 22 Regulations, no deficiencies are being cited on todays visit.

Exit Interview conducted. A copy of the report was provided
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024
LIC809 (FAS) - (06/04)
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