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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000109
Report Date: 11/19/2021
Date Signed: 11/19/2021 01:37:45 PM

Document Has Been Signed on 11/19/2021 01:37 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, 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: DATE:
11/19/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:22 PM
MET WITH:TIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced plan of correction visit to follow up on citations issued on 11/05/2021. LPA was greeted and granted entry into the facility by Care Staff Phyllis Edwards and explained the reason for the visit.

At 1:32 PM, LPA toured the facility and observed the following:

*Deficiency cited under Title 22 Regulation 80087(g) pertaining to Inaccessible Items has been cleared. Noted items have been secured. Licensee has complied with the terms of the POC.


Licensee has been advised to post the 'Let Us No" poster in the entrance of facility at regulation size of 20" X 26."







Exit interview conducted and a copy of this report as well as clearance letter was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2021
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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