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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 01:50:17 PM

Document Has Been Signed on 12/17/2024 01:50 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:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:40 PM
MET WITH:Remedios Sullara, Administrator TIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 12/17/2024 at 1:40 PM, Licensing Program Analysts (LPAs) Patricia Manalo and Luisa Fontanilla arrived at the facility to conduct a case management visit related to an incident reported by the facility. Department of Disability Services (DDS) Nurse Consultant Kasie Gie was also present during the visit. LPAs explained to the Administrator the purpose of the visit.

The facility self-reported an incident when Staff 1 (S1) allegedly "yanked" Client 1 (C1) hand during lift transfer. During the visit, LPAs interviewed the Regional Director, Chris Park, on the phone to obtain information. Park states that S1 is currently suspended pending investigation.

LPAs obtained training records for S1.

Park will provide CCLD investigation findings once completed.

A copy of this report was provided to the Administrator.
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.

LIC809 (FAS) - (06/04)
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