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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604133
Report Date: 03/08/2023
Date Signed: 03/08/2023 12:23:03 PM

Document Has Been Signed on 03/08/2023 12:23 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:ELYON HOME CAREFACILITY NUMBER:
374604133
ADMINISTRATOR:VELASCO, JOFELFACILITY TYPE:
735
ADDRESS:635 S HARBISON AVETELEPHONE:
(619) 259-2560
CITY:NATIONAL CITYSTATE: CAZIP CODE:
91950
CAPACITY: 6CENSUS: 5DATE:
03/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Administrator Jofel VelascoTIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Iby Strong, conducted an unannounced Case Management Visit. LPA met with Direct Care Staff Maggie Adamos and we discussed the purpose of the visit. Administrator Jofel Velasco arrived shortly after.

Today's visit is in response to the self reported death of Client 1 (C1 - see LIC811 Confidential Names List). C1 passed away at the hospital on 3/3/2023.

LPA conducted a wellness check at the facility, and no health or safety issues were identified. Clients observed appeared appropriate for the facility. Interviews were conducted with staff present and additional facility records were obtained on this date. No deficiencies were cited or observed on this date.

An exit interview was conducted with Administrator Jofel Velasco and they were provided with a copy of their appeal rights (LIC9056 03/22) along with a copy of this report.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2023
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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