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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000109
Report Date: 11/05/2021
Date Signed: 11/05/2021 11:36:55 AM

Document Has Been Signed on 11/05/2021 11:36 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ELPHYLL HOMESFACILITY NUMBER:
306000109
ADMINISTRATOR:O'NEAL, NICOLEFACILITY TYPE:
735
ADDRESS:4602 KIMBERWICK CIRCLETELEPHONE:
(949) 653-1709
CITY:IRVINESTATE: CAZIP CODE:
92604
CAPACITY: 3CENSUS: 2DATE:
11/05/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Gwendolyn O'NealTIME COMPLETED:
09:45 AM
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Licensing Program Analysts (LPAs) Kimberly Lyman and Jerome Haley made an unannounced case management visit to the facility to follow up on an incident report submitted to Community Care Licensing on 10/29/2021. LPAs were greeted and granted entry into the facility by Administrator Gwendolyn O'Neal and explained the reason for the visit.

Incident report dated 10/23/2021 indicated Client 1 (C1) ran out of the house, tripped and fell in the street. Staff followed C1 and observed the client lying in the street yelling. Staff noted the client to be having a schizophrenic episode. Client stated his leg hurt and 911 was called. Client was transferred to Hoag Hospital and diagnosed with a broken femur. Client remains hospitalized to date. Per facility documentation, C1 is diagnosed with Paranoid Schizophrenia. Client will be potentially transferred to a skilled nursing for rehabilitation. Facility to keep LPA updated on client's status. No further action required.





A copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2021
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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