<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015202111
Report Date: 10/21/2022
Date Signed: 10/21/2022 04:34:55 PM

Document Has Been Signed on 10/21/2022 04:34 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 - OLYMPIADFACILITY NUMBER:
015202111
ADMINISTRATOR:MARIO P. RODRIGUEZFACILITY TYPE:
734
ADDRESS:32744 OLYMPIAD CTTELEPHONE:
(510) 475-5532
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 5CENSUS: 4DATE:
10/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Thena Valenzuela: LVNTIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/21/2022 at 2:10 PM, Licensing Program Analysts (LPA) L. Fici arrived unannounced to conduct an Infection Control Inspection. LPA met with LVN, Thena Valenzuela and explained the purpose of the visit. At 2:35 PM, Mario P. Rodriguez Administrator (ADM) arrived to facility and greeted LPA.

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. Fire extinguisher is maintained and was last serviced on 1/3/2022. Water temperature is measured at 114.3.

During record review, LPA observed visitors log and temperature log for staff and clients. LPA observed facility has a copy of Infection Control Plan on file. LPA observed PPE’s, food, and paper supplies are sufficient.

Exit interview conducted with Administrator, appeal provided along with this report.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1