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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015202110
Report Date: 12/08/2022
Date Signed: 12/08/2022 11:02:47 AM

Document Has Been Signed on 12/08/2022 11:02 AM - 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:
12/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Care Staff- Genalina BocalaTIME COMPLETED:
11:10 AM
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On 12/8/2022 at 9:25 AM, Licensing Program Analysts (LPA) L. Fici arrived unannounced to conduct an Infection Control Inspection. LPA was greeted and met with care staff, Genalina Bocala and explained the purpose of the visit. At 9:43 AM, Mario P. Rodriguez Administrator (ADM) gave care staff consent to tour and sign the report on his behalf.

Upon entry, LPA's temperature was checked and was asked screening questions. LPA observed hand sanitizer at screening station. LPA toured facility including but not limited to bedrooms, bathrooms, common areas, kitchen, garage, and outdoor area. LPA observed cough etiquette, physical distancing, and signs & symptoms posted in the common areas. All hand washing stations were equipped with soap, paper towel and garbage can with a lid. Hand washing signs were posted at sinks and bathrooms. Facility has a 2-day perishable and 7-day non-perishable food supply. Fire extinguisher is maintained and was last serviced on 1/3/2022. Water temperature is measured at 111.7 Degrees F. Facility room temperature is maintained at 72 degrees F.

During record review, LPA observed a copy of their infection control plan, along with their disaster plan on file.

No deficiencies cited during visit.

Exit interview conducted with care staff, and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2022
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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