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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 11:39:26 AM

Document Has Been Signed on 11/05/2021 11:39 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:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:46 AM
MET WITH:Gwendolyn OnealTIME COMPLETED:
11:55 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Kimberly Lyman and Jerome Haley conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPAs were greeted and granted entry into the facility by Administrator Gwendolyn Oneal and explained the reason for the visit. Gwendolyn Oneal has an administrator certificate and just submitted all the requirements for renewal.

Upon entry, LPAs toured the facility with Administrator Gwendolyn. Facility has two clients present during today's visit, with one clients in the hospital. LPAs observed clients relaxing in the facility. Both clients appeared happy and well taken care of. All client rooms had the required elements and appeared to be well equipped for clients enjoyment. The restroom was clean and stocked with soap. LPAs observed hand sanitizer in the entrance of the facility. The facility mitigation plan has been completed and approved. LPAs observed adequate emergency food as well as the first aid kit with all required items. LPAs observed a medication cabinet with a lock on it. While touring the garage at approx.10:00am, LPAs noticed there were unsecured laundry detergents sitting on top the washing machine. Fire extinguishers are mounted and charged. While touring the kitchen area at approx. 10:05am LPAs observed an unlocked cabinet with unsafe items such as: bleach, raid, and cascade pods. LPAs also observed an unlocked cabinet above the stove with a knife and scissors. LPAs toured the outside grounds and observed a shaded visitation area with a table and chairs. Exit gates are unlocked and self latching.

LPAs consulted with Administrator on the importance of having a screening station set up at the entrance of the facility, and screening all visitors, residents, and staff daily and keeping documentation of the screening process. Further, LPAs consulted Administrator on the importance of keeping unsafe products locked and secured at all time.
Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility Administrator and a copy was provided as well as appeal rights.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
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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Document Has Been Signed on 11/05/2021 11:39 AM - It Cannot Be Edited


Created By: Jerome Haley On 11/05/2021 at 11:11 AM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ELPHYLL HOMES
FACILITY NUMBER: 306000109

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Disenfectants, cleaning solutions, poisions, firearms and other items that could pose a danger if rediable available to clients shall be stored where inaccesible to clients.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPAs observed an unlocked cabinent with bleach, raid, and cascade pods. There was also a unlocked cabinet above the stove that contained a knife and scissors. The garage of the facility was also unlocked and there were unsecured laundry detergents. This poses an immediate health and safety risk to persons in care
POC Due Date: 11/06/2021
Plan of Correction
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Licensee to secure noted items, and will provide proof 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:Luz Adams
LICENSING EVALUATOR NAME:Jerome Haley
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2021


LIC809 (FAS) - (06/04)
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