<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602217
Report Date: 06/11/2024
Date Signed: 06/11/2024 08:52:10 AM


Document Has Been Signed on 06/11/2024 08:52 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:ELWYN CALIFORNIA - NOVARROFACILITY NUMBER:
198602217
ADMINISTRATOR:VERNON VAN RODRIGUEZFACILITY TYPE:
735
ADDRESS:1027 NOVARRO STTELEPHONE:
(626) 699-1889
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY:4CENSUS: 4DATE:
06/11/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:24 AM
MET WITH:Julienna Barrera TIME COMPLETED:
08:40 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Christine Wong generated this Case Management - Deficiencies evaluation report in conjunction with Complaint Control # 28-AS-20240503133047 and made the following observation. While LPA conducted the complaint investigation, LPA conducted the interview with staff and two staff members at the facility will cut clients hair and charge them $30.00 per haircut from their P&I monies. Staff members interviewed confirmed that haircuts are provided to clients and indicated that the facility house manager approved of this. Additionally, LPA conducted a review of clients P&I Ledger and observed handwritten receipts for the haircuts and some receipts were missing from two clients’ P&I Records. LPA also interviewed the facility administrator and facility regional director indicated that they were unaware that facility staff was charging the clients for haircuts.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiencies and issued a citation.

An exit interview was conducted and a copy of the Report and Appeal Rights were provided to Administrator Patria Dufrene.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:
DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2024
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 2


Document Has Been Signed on 06/11/2024 08:52 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: ELWYN CALIFORNIA - NOVARRO
FACILITY NUMBER: 198602217

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/18/2024
Section Cited
CCR
80064(a)(4)

1
2
3
4
5
6
7
80064 Administrator - Qualifications and Duties (a) The administrator shall have the following qualifications:
(4) Ability to maintain or supervise the maintenance of financial and other records.
The requirement was not met as evidenced by
1
2
3
4
5
6
7
The administrator will write up a plan and how to maintian or supervise the maintenacne of financial an other records in the facility and send to LPA by POC due date.
8
9
10
11
12
13
14
LPA's interviews and record reviewed and LPA observed observed handwritten receipts for the haircuts and some receipts were missing from two clients’ P&I Records and two staff confirmed they provided haircuts for clients and charged $30 which facility administrator was not aware of it.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:
DATE: 06/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2