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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000109
Report Date: 11/13/2024
Date Signed: 11/13/2024 03:24:14 PM

Document Has Been Signed on 11/13/2024 03:24 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ELPHYLL HOMESFACILITY NUMBER:
306000109
ADMINISTRATOR/
DIRECTOR:		O'NEAL, NICOLEFACILITY TYPE:
735
ADDRESS:4602 KIMBERWICK CIRCLETELEPHONE:
(949) 653-1709
CITY:IRVINESTATE: CAZIP CODE:
92604
CAPACITY: 3CENSUS: 3DATE:
11/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Phyllis Edwards, LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Phyllis Edwards, Licensee at 1:00 PM.

The facility is a single- story building with four bedrooms and one client bathroom and one private bathroom with an approved fire clearance for two ambulatory and one non-ambulatory client. The facility currently has a census of three clients in care.

During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors and testing hot water temperature in one of one client bathroom. At 1:30 PM the hot water temperature measured was 125.6 degrees Fahrenheit. Licensee was asked to lower the water heater temperature at time of visit. Smoke and carbon monoxide detectors were operational. All client bedrooms had the required furnishings and clean linens. The fire extinguisher was charged and was serviced on October 30, 2024. The facility’s last fire drill was conducted on July 25, 2024.

The attached garage had additional emergency supplies and a washer and dryer. LPA observed a shaded seating area in the backyard and both exterior gates were self-latching. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. Sharps and toxins were secured with a lock. LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed.

At 2:00 PM clients returned from Adult Day Program (ADP) and greeted LPA. LPA interviewed alert clients regarding their quality of care and spoke to staff present regarding care provided. Two clients watched television in the living room and one client chose to be in his bedroom.
(Continued on LIC 809-C)
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ELPHYLL HOMES
FACILITY NUMBER: 306000109
VISIT DATE: 11/13/2024
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(Continued from LIC 809)

LPA reviewed two of two staff training and fingerprint records and conducted a complete review of client records. Upon review of three of three client files, all files were missing Medical Assessments. Client P&I records were reviewed and were not accurate since receipts were with Administrator who was unavailable at the time of the visit. Admissions Agreements on file were in compliance with Title 17 and LPA advised Licensee to create Admissions Agreements to comply with Title 22 with a Technical Violation. LPA confirmed that administrator, Gwendolyn "Nicole" O'Neal has a current administrator certificate which expires on October 27, 2025.

The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.
An exit interview was conducted with Phyllis Edwards, Licensee and a copy of this report was given to the facility along with a copy of the LIC 858, LIC 859; LIC 9102-TV and LIC 809-D and Appeal Rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/13/2024 03:24 PM - It Cannot Be Edited


Created By: RoseMarie Ruppert On 11/13/2024 at 02:56 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: 11/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in one of one client bathrooms which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/14/2024
Plan of Correction
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Licensee was asked to lower the water heater temperature to ensure the water temperature range is between 105 and 120 degree Fahrenheit. LPA measured the water temperature at time of exit and hot water temperature was at 120.0 degrees. Licensee to monitor.
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:Alisa Ortiz
LICENSING EVALUATOR NAME:RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/13/2024 03:24 PM - It Cannot Be Edited


Created By: RoseMarie Ruppert On 11/13/2024 at 02:56 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: 11/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 LPA record review and observation, the licensee did not comply with the section cited above in three of three client records which were missing Medical Assessments which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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Licensee/ Administrator will email LPA the Medical Assessments for the three clients and place the original in the clients' files by POC due date. Please email: RoseMarie.Ruppert@dss.ca.gov.
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:Alisa Ortiz
LICENSING EVALUATOR NAME:RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2024


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