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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015202110
Report Date: 09/01/2022
Date Signed: 09/01/2022 06:11:49 PM

Document Has Been Signed on 09/01/2022 06:11 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:
09/01/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Mario Rodriguez/AdministratorTIME COMPLETED:
04:00 PM
NARRATIVE
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While at the facility conducting complaint investigation (Complaint # 15-AS-20220826164708), Licensing Program Analyst (LPA) Delmundo learned from Mario Rodriguez, administrator, that the facility staff/LVN (S1) started working January 1, 2021. LPA checked Community Care Licensing (CCL) Guardian Portal and LIS Facility Employee Roster, and observed S1's name not on CCL's system.

LPA discussed the above with the Mario Rodriguez.

Deficiency is cited from Title 22 California Code of Regulations and listed on LIC809D). A $500.00 civil penalty is assessed for deficiency section 1569.17(b)(2)(E). Failure to submit proof of correction by plan of correction due date may result in additional civil penalty.

Deficiency and plan, and proof of correction were discussed.

Exit interview conducted. Appeal Rights, LIC421BG Civil Penalty Assesment. LIC9098 Proof of Correction form, and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2022
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 09/01/2022 06:11 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 09/01/2022 at 05:35 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: 09/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/02/2022
Section Cited
HSC
1569.17(b)(2)(E)

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ยง1569.17 Fingerprints and criminal records of individuals in contact with clients...(b) (2)(E) Licensed or certified medical professionals are exempt from fingerprint and criminal background check requirements imposed by community care licensing. This exemption does not apply to a person who is a community care facility ......
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Administrator will have the staff fingerprint and associated and submit proof by 9/02/2022.

A $500.00 civil penalty is assessed.
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,,,,,,,licensee or an employee of the facility.

-This requirement is not met as evidenced by;

-Based on records review, the licensee did not comply with the section above for not having the staff fingerprint and associated. A civil penalty is assessed.
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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:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022


LIC809 (FAS) - (06/04)
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