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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004248
Report Date: 07/26/2024
Date Signed: 07/26/2024 02:18:01 PM

Document Has Been Signed on 07/26/2024 02:18 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ELWYN NC - BARNWALLFACILITY NUMBER:
306004248
ADMINISTRATOR/
DIRECTOR:		TERESA OPORTOFACILITY TYPE:
735
ADDRESS:15319 BARNWALL STTELEPHONE:
(714) 670-8600
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY: 4CENSUS: 3DATE:
07/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:59 AM
MET WITH:DSP Erick RosalesTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met with DSP worker Erick Rosales at approximately 11:49 AM and explained the reason for the visit. Administrator Crysel Santos arrived shortly after.

This home provides services for three (3) non ambulatory developmentally disabled adults ages 18-59 with restricted health conditions.

The facility is a single-story home located in a residential neighborhood that is licensed for a capacity of four (4) clients. It consists of four (4) client bedrooms, a living room, a dining room, a kitchen, two (2) client bathroom, one (1) staff office, a front yard area, a back patio area, and a garage.

LPA toured the facility and observed the following: Three (3) out of four (4) client bedroom has the required furniture and bedding C#1 was missing chair TV given. There is extra clean linen and towels in a hallway closet. Smoke detectors were observed in each room and throughout the facility and are properly operating. There is 1 carbon monoxide in the kitchen and is properly operating. The facility has one (1) fully charged fire extinguishers which is kept in the kitchen. Cleaning supplies and toxic are locked in laundry room. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 45 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. Sharps are locked and placed in drawer in kitchen. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the clients in backyard. Passageways and exits are free of obstruction. The garage is clean and has one large refrigerator and extra hygiene supplies for clients.

SEE LIC 809C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ELWYN NC - BARNWALL
FACILITY NUMBER: 306004248
VISIT DATE: 07/26/2024
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Four (4) Staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Three (3) Client files were reviewed and included physicians report, TB clearance, and individual program plan (IPP)report. Last fire/earthquake drill was conducted in July of 2024. Infectious control plan will be sent via email to LPA. The medications are centrally stored and locked in a cabinet in kitchen. The facility uses the Medication Administration Record (MAR) log to document medications given. LPA reviewed medications for all clients, and they are being administered as prescribed by the physician.

No deficiency was observed during today’s visit. Exit interview was conducted with Administrator Santos and a copy of report was provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024
LIC809 (FAS) - (06/04)
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