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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015202110
Report Date: 03/11/2025
Date Signed: 03/13/2025 02:23:43 PM

Document Has Been Signed on 03/13/2025 02:23 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/
DIRECTOR:		REMEDIOS SULLARAFACILITY TYPE:
734
ADDRESS:8101 MEADOWLARK CTTELEPHONE:
(510) 797-7940
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY: 5CENSUS: 5DATE:
03/11/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Sabrina Balal, LVNTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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On this day at around 12:40 PM, LPA Luisa Fontanilla arrived unannounced to conduct a case management visit and met with LVN Sabrina Balal. LPA explained to Balal the purpose of the visit. The interim Administrator Ruby Abalos was informed about the visit over the phone and authorized Balal to sign the report.

This case management visit is being conducted as follow up on the annual review conducted by DDS Nurse Consultant on January 22, 2025 .

Deficiencies were cited per Title 22 California Code of Regulations and Health and Safety Code (refer to Lic 809D).

A copy of this report and Appeal Rights was provided to Balal.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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 03/13/2025 02:23 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 03/11/2025 at 10:17 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: 03/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/21/2025
Section Cited
CCR
80065(a)

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80065(a) Personnel Requirements
This requirement is not met as evidenced by:
(a) Facility personnel shall be competent...
This requirement is not met as evidenced by: A licensed staff was observed flushing the gastrostomy tube (GT) of a client. During the procedure of verifying the GT placement, the staff person was seen pushing air through the tube and auscultating the stomach.

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Training on GT will be conducted and proof of training will be submitted to CCL by POC date.
Type B
03/13/2025
Section Cited
HSC
1538.55(a)

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HSC Section 1538.55(a) Events requiring reports by licensee; notice of findings
(a) The licensee of an Adult Residential Facility for Persons with Special Health Care Needs (ARFPSHN) or a Group Home for Children with Special Health Care Needs (GHCSHN), licensed pursuant to Article 9 (commencing with Section 1567.50), shall report to the department’s Community Care Licensing Division, within the department’s next working day..
This requirement is not met as evidenced by:
An SIR notification was sent on 11/27 for an incident that occurred on 11/21.
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Proof of staff training was provided to LPA during visit. This deficiency is cleared.
Type B
03/13/2025
Section Cited
CCR80076(a)(1)

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80076(a) Food Services
(a) In facilities providing meals to clients, the following shall apply:(1) All food shall be safe and of the quality and in the quantity ...
This requirement is not met as evidenced by: The following were observed: An opened bag of Eggo waffles was unsealed and 2 eggo waffles were exposed and on top of plastic ice packs.

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Proof of training on Proper Food Preparation and Food Safety was provided to LPA during the visit. This deficiency is cleared.
Type B
03/13/2025
Section Cited
CCR
80087(a)(1)

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80087(a)(1) Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair...
(1) The licensee shall take measures to keep the facility free of flies and other insects.
This requirement is not met as evidenced by: Screens on windows were seen separated from the panes thereby potentially allowing insects to enter the facility.

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During the visit, LPA inspected all window screens which appeared to be in good condition. Balal states all window screens have been replaced.
This deficiency is cleared.
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: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/13/2025 02:23 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 03/11/2025 at 10:47 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: 03/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/13/2025
Section Cited
CCR
80076(a)(6)

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80076(a)(6) Food Services
(a) In facilities providing meals to clients, the following shall apply:
( 6) Modified diets prescribed by a client's physician as a medical necessity shall be provided. This requirement is not met as evidenced by: Based on review of menus conducted, menus were
not individualized for the 4 clients
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Staff provided LPA individualized menus for all 4 clients.
This deficiency is cleared during the visit.
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who eat by mouth. The reviewed diet orders for 3 clients indicated they have specialized diets.
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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: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025


LIC809 (FAS) - (06/04)
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