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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015202110
Report Date: 09/14/2021
Date Signed: 09/14/2021 05:24:35 PM

Document Has Been Signed on 09/14/2021 05:24 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ELWYN NC - MEADOWLARKFACILITY NUMBER:
015202110
ADMINISTRATOR:MARIO P. RODRIGUEZFACILITY TYPE:
734
ADDRESS:8101 MEADOWLARK CTTELEPHONE:
(510) 797-7940
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY: 5CENSUS: 5DATE:
09/14/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Mario Rodriguez, AdministratorTIME COMPLETED:
06:00 PM
NARRATIVE
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On 09/13/21 at 3:15PM, LIcensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced case management visit as a result of receiving 5 self reported incidents dated 09/02/21 submitted to CCLD regarding clients' lack of supervision at the facility. LPA explained the purpose of the visit with administrator (ADM). Routine COVID-19 symptom checks was done to LPA by staff wearing face mask at the front entrance. LPA observed 5 clients sitting comfortably in their own individual wheelchairs and 4 staff wearing face masks during visit. Two clients were watching TV in the living room while the other 3 clients were resting inside their bedrooms.

ADM stated to LPA that he received a progress report dated 09/01/21 from staff (S1) who stated that one morning, LVN (S2) and another CNA (S3) on AM shift duty left the facility before 8AM to buy chips and dip at a local store, leaving 2 other CNA's (S1 and S5) providing care to 5 clients for over 20 minutes. ADM stated 1 client (R1) require 24 hour one-on-one care while another client (R3) require 10 hours one-on-one care.

LPA interviewed S5 who confirmed that both S2 and S3 were not at the facility between 7:30AM and 8AM when he needed to administer R1's scheduled AM medications. S5 witnessed S2 and S3 come back to the facilty with chips and dip past 8AM. S5 stated this incident happened 4 or 5 months ago and could not remember the exact date. ADM stated he only knew about this incident when he received the progress report from S1 on 09/01/21.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099 D. Failure to submit proofs of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2021
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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Document Has Been Signed on 09/14/2021 05:24 PM - It Cannot Be Edited


Created By: Daisy Panlilio On 09/14/2021 at 04:59 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ELWYN NC - MEADOWLARK
FACILITY NUMBER: 015202110

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2021
Section Cited
CCR
80078(a)

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Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision as necessary to meet the client's needs.
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Administrator agreed to submit to CCLD on or before POC due date staff re-training certifications from an accredited trainer/vendor on staff responsibilities for providing proper care and supervision to clients.
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This requirement was not met as evidenced by lack of supervision of 5 clients by licensed professional which posed a potential health & safety risk to clients in care.
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Type B
09/30/2021
Section Cited
CCR80061(b)

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Reporting Requirements
(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.
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Administrator agreed to submit to CCLD on or before POC due date proof of correction that staff has completed re-training on reporting requirements as outlined in Title 22 Section 80061 (b)
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This requirement was not met as evidenced by non reporting of incident on the day it happened which posed a potential health & safety risk to clients in care.
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Administrator will submit copy of signed and completed staff re-training certification on reporting requirements to CCLD on or before POC due date.
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:Bennett Fong
LICENSING EVALUATOR NAME:Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2021


LIC809 (FAS) - (06/04)
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