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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004423
Report Date: 08/03/2022
Date Signed: 08/03/2022 02:10:36 PM

Document Has Been Signed on 08/03/2022 02:10 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ELWYN NC - LARRYLYNFACILITY NUMBER:
306004423
ADMINISTRATOR:TERESA OPORTOFACILITY TYPE:
735
ADDRESS:10915 LARRYLYN DRTELEPHONE:
(562) 315-5505
CITY:WHITTIERSTATE: CAZIP CODE:
90603
CAPACITY: 4CENSUS: 4DATE:
08/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Eva Gallardo, House ManagerTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection with the focus of the Infection Control Practice domain. LPA arrived unannounced and met with house manager, Eva Gallardo. The purpose of the visit was explained.

LPA toured the facility inside and out and the following were observed:

* The facility is a one-story home with 4 bedrooms, 2 bathrooms, living room, dining room, kitchen, office area, laundry area, and an attached garage. The spacious outdoor consists of shaded areas. There are no pools or bodies of water at the premises.
* COVID-19 signage are posted at the front door and throughout the home.
* Staff continue to take the temperature and conduct COVID-19 screening prior to entering the facility.
* PPE supplies for at least 30 days such as gowns, gloves, and masks were observed.
* Staff are cleaning and disinfecting on every shift.
* The hot water temperature was measured between the required range of 105-120 degrees Fahrenheit.
* Extra hygiene supplies are stored and locked in the garage.
* Knives and sharps are locked in the kitchen cabinet located under the sink.
* Medications are centrally stored and locked. LPA reviewed the medications with the medication logs for each resident and no discrepancies were noted.
* There are sufficient food supplies of 2 day perishable and a week of non-perishable.
* Staff on duty were wearing face masks and gowns.

Per the house manager, they are continuing to follow their mitigation plan.

There are no deficiencies issued today. An exit interview was conducted and a copy of this report was given.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2022
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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