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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000109
Report Date: 11/27/2023
Date Signed: 11/27/2023 02:48:30 PM

Document Has Been Signed on 11/27/2023 02:48 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
ORANGE COUNTY ASC, 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: 3DATE:
11/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:01 AM
MET WITH:Administrator - Phyllis EdwardsTIME COMPLETED:
02:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived for an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry by Administrator Phyllis Edwards and Gwendolyn Nicole O'Neal.

The facility is a one-story home with three resident bedrooms, one bathroom, kitchen, dining room, living room, staff room, back yard and attached two-car garage. LPA observed a hole in the wall in the garage, a drawer in the kitchen that was missing a door and a light switch in the bathroom that did not have a covering for the light switch. A deficiency is being issued on this day. All resident rooms had required elements, including bed, chair, closet space and ample lighting. Upon first measuring hot water, it measured over 120 degrees Fahrenheit. The Administrator lowered the temperature on the water heater. Hot water took 90 minutes to cool down. Restroom hot water measured at 110.3 degrees Fahrenheit. LPA observed exit gates in the backyard to be operational and unobstructed. Facility has one shaded seating area in the backyard. Smoke and Carbon Monoxide detectors tested operational. LPA observed facility has emergency food and water supply. Appliances are operational. Facility has a 2-day supply of perishable food and a 7-day supply of non-perishable food. Fire Extinguisher was observed to be fully charged as indicated by the built-in meter. The service tag indicates it was last serviced on 10/12/23. LPA observed client medication and staff files to be locked in the office and clinical room. LPA reviewed medication and files for both clients. LPA observed clients’ health screenings were not in file. LPA also reviewed P&I. One of the three P&I reviewed was short by $200. Facility staff corrected this during the inspection. While reviewing files, LPA noted that the Infection Control Plan was not kept on file. LPA issued a technical violation. LPA also noted that the facility has conducted emergency drills in 2023, but the drills did not occur at least quarterly. LPA issued a technical violation. LPA reviewed two staff files. All clients were away at day program.

Based on today’s inspection, three deficiencies and two technical violations were issued. An exit interview was conducted and a copy of this report was provided.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/27/2023
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 11/27/2023 02:48 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 11/27/2023 at 12:55 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ELPHYLL HOMES
FACILITY NUMBER: 306000109

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above due to the hole in the wall in the garage, the hole in the wall in the living room, the kitchen drawer missing a door and the missing light switch panel in the bathroom. This poses a potential safety risk to persons in care.
POC Due Date: 12/27/2023
Plan of Correction
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Administrator stated facility will hire someone to make the repairs to the items listed. Administrator stated they will notify LPA of the completed work by the assigned POC due date of 12/27/2023.
Type B
Section Cited
CCR
85068.2(b)(1)(C)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as none of the residents had documented medical assessments within the last year. This poses a potential health risk to persons in care.
POC Due Date: 12/27/2023
Plan of Correction
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Administrator stated they will contact the residents' doctors to acquire documentation reflecting doctor visits from 2023. Administrator stated they will send copies of these documents to the LPA via email by the assigned POC due date of 12/27/2023.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:
DATE: 11/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/27/2023 02:48 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 11/27/2023 at 01:06 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ELPHYLL HOMES
FACILITY NUMBER: 306000109

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(h)(1)
(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following:

(1) Records of clients' cash resources maintained as a drawing account, which shall include a current ledger accounting, with columns for income, disbursements and balance, for each client. Supporting receipts for purchases shall be filed in chronological order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on P&I review, the licensee did not comply with the section cited above in one out of three client P&I. This poses a potential personal rights risk to persons in care.
POC Due Date: 12/27/2023
Plan of Correction
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Administrator corrected the error during the LPA's inspection. Administrator stated facility will do a weekly review of P&I and will make updates as they arise. LPA will review P&I again during POC visit which will occur after 12/27/2023.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:
DATE: 11/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2023


LIC809 (FAS) - (06/04)
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