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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015202111
Report Date: 05/04/2023
Date Signed: 05/04/2023 10:58:46 AM

Document Has Been Signed on 05/04/2023 10:58 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 - OLYMPIADFACILITY NUMBER:
015202111
ADMINISTRATOR:MARIO P. RODRIGUEZFACILITY TYPE:
734
ADDRESS:32744 OLYMPIAD CTTELEPHONE:
(510) 475-5532
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 5CENSUS: 5DATE:
05/04/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mario Rodriguez, AdministratorTIME COMPLETED:
11:10 AM
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On this day at around 9:00 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an unannounced case management visit to follow up on Department of Disability Services (DDS) Six-Month Review dated April 18, 2023. LPA met with Administrator Mario Rodriguez and explained the purpose of visit.

During the visit, LPA went over with Administrator areas of concern. Five out of eight areas of concern have been completed. The remaining concerns which facility is currently working on are as follows:

1. Elwyn California is currently revising all training plans and will submit to DDS revised plans for review by
June 30, 2023. Once approved by DDS, Administrator will submit to CCL a copy of proof of approval.

2. Retrain staff on Seizure Flow Sheet and submit proof to CCL by 5/5/2023

3. Administrator will schedule lab work for Client 1 (C1) .

4. A copy of summary of visit for C1's neurologist appointment on May 9, 2023 will be sent to CCL on May 10,
2023.

No deficiencies were noted during the visit.

Exit interview was conducted with Administrator and a copy of this report was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2023
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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