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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000109
Report Date: 01/03/2024
Date Signed: 01/03/2024 09:54:45 AM

Document Has Been Signed on 01/03/2024 09:54 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
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:
01/03/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:46 AM
MET WITH:Administrator - Phyllis EdwardsTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived for an unannounced visit for the purpose of conducting a Plan of Corrections inspection. LPA was greeted and granted entry by Administrator Phyllis Edwards and Gwendolyn Nicole O'Neal.

LPA stated the purpose of the inspection. LPA observed all clients to be away at Day Program. LPA conducted a tour of the facility. LPA observed the holes in the walls in the living room and the garage to be repaired, the drawer in the kitchen to be repaired and the light switch in the bathroom to be repaired.

LPA reviewed P&I for all clients. LPA observed P&I funds to match the ledger as well as the receipts. LPA observed P&I funds to be accounted for and properly documented/stored.

With regard to medical documentation, AD presented Client 1's medical assessment for LPA to review. AD also provided proof that Client 2's medical assessment has been sent via mail and is in transit. AD stated that, upon reaching out to get documentation for Client 3's medical assessments, their doctor stated they are no longer accepting Medi-Cal patients. Administrator stated they began the process of switching Client 3's insurance over to Medi-Care. AD showed LPA Client 3's Medicare Card.

Based on the inspection, it is determined that the facility has corrected all three deficiencies issued at the 11/27/2023 annual inspection. An exit interview was conducted and a copy of this report and POC Clear Letters for all three deficiencies were provided.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2024
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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