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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015202110
Report Date: 12/17/2024
Date Signed: 12/17/2024 01:28:45 PM

Document Has Been Signed on 12/17/2024 01:28 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:
12/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Remedios SulleraTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
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On 12/17/2024 at 9:00AM, Licensing Program Analysts (LPAs) Patricia Manalo and Luisa Fontanilla arrived unannounced to conduct a Required 1 Year Inspection. DDS Nurse Consultant Kasie Gee arrived with LPAs. LPAs met with Licensing Vocational Nurse, Yang Zhang, who phoned the Administrator and explained the purpose of the visit. Administrator, Remedios Sullera, arrived shortly after. The fire clearance is approved for five (5) all may be bedridden.

LPAs toured the facility inside and out including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. Smoke and carbon monoxide combination detectors were observed. Smoke detectors are interconnected with sprinklers system. Fire extinguishers were last serviced on 01/22/2024. One week of non-perishable and 2-day perishable food supplies were sufficient. Hot water temperature was measured at 131.3 degrees Fahrenheit in the hallway bathroom. All client bedrooms have automatic hoyer lifts and bathroom lift installed. Medications were locked in a medication cart. First Aid kit is complete. No bodies of water observed. Last fire drill was conducted on 11/20/2024. Emergency Disaster Drill Plan was last posted on 12/17/2024.

Starting at 9:12 AM, LPAs reviewed all five clients files. At 9:49 AM, LPAs reviewed three files and all three have First Aid Certificate. At 11:15 AM, LPAs reviewed client's P & I money with logs. LPAs reviewed a sample of client's medications during inspection.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 12/26/2024:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610E Emergency Disaster Plan

Continue to LIC 809-C...
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ELWYN NC - MEADOWLARK
FACILITY NUMBER: 015202110
VISIT DATE: 12/17/2024
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THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 9:10 AM, LPAs observed the hot water temperature measured at 131.3 degrees F.

At 9:15 AM, LPAs observed the cleaning supplies under the sink unlocked and accessible to clients.

At 9:20AM, LPAs observed facility side gates were locked. Civil penalty of $500 is being assessed.

At 9:30 AM, LPAs observed broken window blinds, cobwebs on the windows, and overgrown landscape in the backyard.

At 9: 25 AM, LPAs observed shower gurney, foams, and ladder at the backyard passageway.

At 10:00 AM, LPAs observed S3 not associated to the facility on Guardian.

At 12:00 PM, LPAs observed that C4's MAR was not signed off from 12/08/2024 to 12/10/2024.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. A copy of this report, civil penalty, and appeal rights provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
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Page: 6 of 6
Document Has Been Signed on 12/17/2024 01:28 PM - It Cannot Be Edited


Created By: Patricia Manalo On 12/17/2024 at 12:40 PM
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: 12/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having an unlocked cabinet under the kitchen sink with cleaning chemicals which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/18/2024
Plan of Correction
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Staff locked the cabinet during the visit. Deficiency cleared.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having the hot water temperature was measured at 131.3 degrees F which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/18/2024
Plan of Correction
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Administrator agrees to send proof of photo to CCLD of the water temperature within the range by POC date.
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: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 12/17/2024 01:28 PM - It Cannot Be Edited


Created By: Patricia Manalo On 12/17/2024 at 12:40 PM
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: 12/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having the side gate without fire clearance for locked parameter which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/18/2024
Plan of Correction
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Administrator agrees to have the maintaince repairman come to remove the lock from the gate and send proof of picture to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 12/17/2024 01:28 PM - It Cannot Be Edited


Created By: Patricia Manalo On 12/17/2024 at 12:40 PM
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: 12/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above in having broken window blinds, cobwebs on the window, overgrown landscape in the backyard, and kitchen cabinet that has black mold found which poses a potential health and safety risks to persons in care.
POC Due Date: 12/27/2024
Plan of Correction
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Administrator agrees to have the broken window blinds, cobwebs removed, clean the backyard and kitchen, and send proof to CCLD by POC date.
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having a shower gurney, foams and ladder in the back blocking the passageway which poses a potential health and safety risks to persons in care.
POC Due Date: 12/27/2024
Plan of Correction
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The Administrator agrees to remove the items blocking the passageway and send proof to CCLD by POC date.
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: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 12/17/2024 01:28 PM - It Cannot Be Edited


Created By: Patricia Manalo On 12/17/2024 at 12:40 PM
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: 12/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above by not having C4's MAR signed off which poses a potential health and safety risk to persons in care.
POC Due Date: 12/27/2024
Plan of Correction
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The Administrator agrees to send a copy of the signed MAR and proof of staff training to CCLD by POC date.
Type B
Section Cited
CCR
80019(e)(3)

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in not having S3 and ADP staff associated to the facility which poses a potential health and safety risk to persons in care.
POC Due Date: 12/18/2024
Plan of Correction
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Administrator agrees to associate S3 and ADP staff to the facility and send proof to CCLD by POC date.
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: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2024


LIC809 (FAS) - (06/04)
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