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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015202110
Report Date: 02/13/2025
Date Signed: 02/13/2025 12:06:16 PM

Document Has Been Signed on 02/13/2025 12:06 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ELWYN NC - MEADOWLARKFACILITY NUMBER:
015202110
ADMINISTRATOR/
DIRECTOR:		REMEDIOS SULLARAFACILITY TYPE:
734
ADDRESS:8101 MEADOWLARK CTTELEPHONE:
(510) 797-7940
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY: 5CENSUS: 5DATE:
02/13/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Sabrina Balal, Staff TIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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On 02/13/2025 at around 10:45 am, Licensing Program Analysts (LPAS) P.Manalo and L. Fontanilla arrived at the facility to conduct a case management visit related to an incident reported by the facility. LPAs met with staff, Sabrina Balal. Staff contacted Regional Director, Chris Park, to explain the purpose of the visit.

On 02/10/2025, LPA L. Fontanilla received an Incident Report regarding missed seizure medication for client (C1). Based on record review, LPAs observed that the Medication Administration Record (MAR), was signed by staff even though the medication was not provided to C1. Staff on duty confirmed with LPAs that C1's noon seizure medication was not given by S2. C1's seizure episode occurred at around 9am. In regards to the Medication Administration Record (MAR), S1 admitted to signing the MAR despite not giving the medication to C1.

Based on the report, the staff did not provide the 8:00 AM medication and the client had a seizure at around 9 AM. However, staff interviews indicated that the dose that was missed was the 12:00 PM medication.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

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



SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025
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 02/13/2025 12:06 PM - It Cannot Be Edited


Created By: Patricia Manalo On 02/13/2025 at 11:16 AM
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: 02/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/21/2025
Section Cited
CCR
80075(b)

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80075(b) 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:
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The licensee states 1) a corrected copy of the incident will be sent to CCL
2) retraining of staff on medication administration. Proof of training will be sent to CCLD by POC date.
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Based on records and interviews conducted, the licensee did not comply with the section cited above when staff did not provide C1 their seizure medication which poses an immediate health and safety risk to persons in care.
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Type A
02/21/2025
Section Cited
CCR80075(b)(5)(C)

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80075(b)(5)(C) Health Related Services
(C)A record of each dose is maintained in the client's record...

This requirement is not met as evidenced by:
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The Regional Director states the facility will conduct retraining with the staff on medication administration and send proof to CCLD by POC date.
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Based on record review, the licensee did not comply with the section cited above having the Medication Administration Record (MAR) signed without giving the client the medication which poses an immediate health and safety risk to persons 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:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2025


LIC809 (FAS) - (06/04)
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