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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015202110
Report Date: 12/21/2023
Date Signed: 12/21/2023 03:18:58 PM

Document Has Been Signed on 12/21/2023 03:18 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:
12/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Desiree FredelucesTIME COMPLETED:
03:25 PM
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On this day at around 10:25am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection and met with nurse Crisanto Lodia. LPA spoke with Ruby Abalos over the phone and informed her about the purpose of visit. Desiree Fredeluces, Administrator for a different location arrived and assisted LPA with the visit.

During the visit, LPA inspected the facility inside and out including but not limited to client rooms, bathrooms, kitchen and dining area. Hot water in the kitchen measured at 115 degrees Fahrenheit. Temperature in the fridge measured at 42 degrees Fahrenheit and freezer was at 0 Fahrenheit. There was sufficient supply of perishable and nonperishable foods. Medications in the nurse station were observed locked.

At 11:23 am, LPA reviewed 5 client files and 4 staff files. All staff were observed to be fingerprint cleared and associated to the facility. All staff present were observed fingerprint cleared and associated to the facility.

At around 1:30 pm, LPA reviewed P&I money and log. Facility has surety bond sufficient to cover amount of cash being handled at one time. First aid kit was observed complete. Fire extinguisher appeared full and last inspected on 1/5/2023. At 2pm, LPA reviewed medication and Medication Administration Record (MAR) with LVN Crisanto Lodia.

LPA obtained the following records during the visit:
  • Surety Bond
  • Lic 308
  • Emergency Disaster Plan
  • Infection Control Plan
  • Liability insurance continuation on Lic 809C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ELWYN NC - MEADOWLARK
FACILITY NUMBER: 015202110
VISIT DATE: 12/21/2023
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Smoke detectors and fire alarms were inspected by third party contractor on July 18, 2023. The last fire/earthquake drill was conducted on 10/30/2023. Generator was last tested on 12/8/2023.

There is no deficiency noted for the visit.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC809 (FAS) - (06/04)
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