Community Care Licensing

Document Has Been Signed on 09/26/2024 03:43 PM - It Cannot Be Edited

FACILITY NAME:	ELWYN NC - MEADOWLARK		FACILITY NUMBER:	015202110
ADMINISTRATOR/ DIRECTOR:	MARIO P. RODRIGUEZ		FACILITY TYPE:	734
ADDRESS:	8101 MEADOWLARK CT		TELEPHONE:	(510) 797-7940
CITY:	NEWARK	STATE: CA	ZIP CODE:	94560
CAPACITY: 5		CENSUS: 5	DATE:	09/26/2024
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:50 PM
MET WITH:	Cynthia Octabiano, Interim Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:20 PM

SUPERVISORS NAME: Yvonne Flores-Larios LICENSING EVALUATOR NAME: Luisa Fontanilla LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024

Link to Parent Document Below:

FACILITY NAME: ELWYN NC - MEADOWLARK	FACILITY NUMBER: 015202110
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/26/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/26/2024 Section Cited CCR 80066(a)(6)	1 2 3 4 5 6 7	80066 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the ... (6) Documentation of the educational background, training and/or experience specified in licensing regulations for the type of facility in which the employee works.	1 2 3 4 5 6 7	S2 completed DSP2 training on 8/31/24. For S1 required training, doctor order/no training is needed. This deficiency is cleared.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on record review conducted, the facility did not have proof of training on file for S1 and S2 which poses a potential risk to health and safety of clients under care.	8 9 10 11 12 13 14
Type B 09/26/2024 Section Cited CCR80075(a)	1 2 3 4 5 6 7	80075 Health Related Services (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.	1 2 3 4 5 6 7	Octabiano provided LPA a copy of the client's July 2024 doctor visit and 8/1/24 dietitian visit. This deficiency is cleared today.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on record review conducted by DDS, the facility failed to assist client in arranging medical/dietitian appointments which poses a potential risk to the health and safety of clients under care.	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Yvonne Flores-Larios LICENSING EVALUATOR NAME: Luisa Fontanilla LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024

Link to Parent Document Below:

FACILITY NAME: ELWYN NC - MEADOWLARK	FACILITY NUMBER: 015202110
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/26/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/26/2024 Section Cited CCR 80075(b)	1 2 3 4 5 6 7	80075 Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidenced by: Based on record review codnucted by DDS,	1 2 3 4 5 6 7	The Administrator provided LPA a copy of the signed MAR and proof of staff training. This deficiency is cleared.
	8 9 10 11 12 13 14	the facility failed to sign off MAR for client's PRN(Mylanta) which poses a potential risk to the health and saety of clients under care.	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

SUPERVISOR'S NAME: Yvonne Flores-Larios LICENSING EVALUATOR NAME: Luisa Fontanilla LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024