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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015202110
Report Date: 08/15/2023
Date Signed: 08/15/2023 02:17:34 PM

Document Has Been Signed on 08/15/2023 02:17 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:
08/15/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Mario RodriguezTIME COMPLETED:
02:45 PM
NARRATIVE
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On this day at around 1:30 PM, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct a case management visit in connection with the 6-month review conducted by the Department of Developmental Disabilities (DDS) on 7/26/2023. LPA was met by staff Genaline Bocala. Administrator Mario Rodriguez arrived at around 1:40 pm.

A review of DDS six-month review indicate Client 1 (C1) laboratory were not fulfilled over the past months.

Deficiency is cited per Title 22 California Code of Regulations (refer to Lic 809D).

Exit interview was conducted with Administrator and Appeal Rights was conducted.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2023
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 08/15/2023 02:17 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 08/15/2023 at 01:51 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: 08/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/18/2023
Section Cited
CCR
80075(a)

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CCR 22 ยง80075 (a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services.
This requirement is not met as evidenced by:
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Administrator states C1 did bloodwork on 8/15, visited PCP on 8/15/2023 and an inhouse phlebotomist has been contacted to repeat blood work per PCP order.
Deficiency is cleared.
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Based on record review, C1 laboratory work were not fulfilled over the past months which poses a potential risk to health and safety of clients in care.
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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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2023


LIC809 (FAS) - (06/04)
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