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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004423
Report Date: 08/24/2023
Date Signed: 08/24/2023 03:56:19 PM


Document Has Been Signed on 08/24/2023 03:56 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:
08/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administrator Edward VelardeTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Jose Villalobos, conducted a required annual inspection using the Inspection Tool. LPA met with Staff Eva Gallardo and the purpose of the visit was discussed. Administrator Edward Velarde arrived shortly after

Structure/Physical Plant: The facility is part of a single story home located in a residential area and contains the following: living room, dining room, kitchen with refrigerator, oven, stove, dishwasher, sink/faucet, locked storage cabinet for medications and sharps, (4) client rooms, (2) bathrooms for clients; bathrooms with shower, toilet and washbasin. A back yard with shaded area and seating for client use. There's a laundry area; with washer and dryer. The residence is equipped with central air conditioning.Accommodations: Adequate accommodations observed throughout facility. Hallway and Doorways: Free and clean of obstruction and debris. Client Rooms: All bedrooms are equipped with: overhead lighting, chair, night stand, lamp in addition to overhead lighting, large drawer, and closet space. Bathrooms: All bathrooms have a working toilet, wash basin, shower, grab bars and nonskid mats. Linens & Hygiene Supplies: Required linen/supplies observed. Emergency Phone Numbers, Exit Plan & Menu: Facility has a working phone landline. There is a cordless phone for client use. Fire Extinguisher observed Food Service: All food and adequate utensils such as, dishes, cups, bowls and plates observed. Smoke Detectors & Fire Extinguishers: Detectors Electrical & connected. All detectors operational. Toxins: Locked/stored for staff use only. Hot Water Temperature: Measured between 105 -115 degrees all around the home. Medications, First-Aid Kit & Book: Medications centrally stored and inaccessible to clients. First aid kit observed. Postings: Wall postings observed. Clients & Staff Files: LPA reviewed (4) of (4) client medication records and files , as well as five(5) Staff Files . Emergency Disaster, Infection Control, and Plan of Operation also observed.



Inspection tool completed and no deficiencies are being cited. Exit Interview conducted and a copy of this report was provided
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
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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