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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015202111
Report Date: 08/25/2023
Date Signed: 08/25/2023 01:44:48 PM

Document Has Been Signed on 08/25/2023 01:44 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: 5DATE:
08/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mario RodriguezTIME COMPLETED:
02:00 PM
NARRATIVE
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On this day at around 9am, Licensing Program Analysts (LPAs) Luisa Fontanilla and Alona Gomez arrived at the facility to conduct an annual required inspection. LPAs were met by LVN Thena Valenzuela. Administrator Mario Rodriguez arrived at the facility at a later time to assist with the inspection.

During the visit, LPAs inspected the facility inside and out including but not limited to client rooms, bathrooms, kitchen, garage, backyard. There were 5 clients, 2 LVNs and 1 CNA observed upon arrival.
The facility has an approved fire clearance for 5 non ambulatory clients. Multiple fire extinguishers that appeared full and has tag date of 2/5/2023 were observed. Carbon monoxide was tested and observed operational. The last inspection of smoke detectors was conducted on on 4/25/2023 by Hue & Cry Inc..
Last fire/earthquake drill was conducted on 8/22/2023. Generator was tested on 8/22/2023. First aid was observed complete.

At around 9:10 am, LPAs reviewed 5 client and 5 staff files. At 12:25 pm, LPAs reviewed P&I money and log. Facility has a bond in the amount of 11,000 which is sufficient to cover amount of cash being handled at one time.

The following deficiencies were observed:
  • at around 9:35 am, a box of medicines unlocked in the front area
  • at around 9:40 am, steak knife, hammer and thumb tacks unlocked in the kitchen
  • at around 9:50 am, one client room with screen window broken and with holes
  • at around 9:53 am, unlocked chemical in the backyard storage
  • at around 9:55 am, one client room missing a window screen
continuation on Lic 809C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2023
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 - OLYMPIAD
FACILITY NUMBER: 015202111
VISIT DATE: 08/25/2023
NARRATIVE
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  • at around 10:01 am, LPAs observed unlocked chemical in the small bathroom
  • at around 9:45 am, LPAs observed that both side gate exit doors do not open easily



Deficiencies are cited per Title 22 California Code of Regulations. Refer to Lic 809 C.

Exit interview was conducted with Administrator and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
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Document Has Been Signed on 08/25/2023 01:44 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 08/25/2023 at 12:20 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 - OLYMPIAD
FACILITY NUMBER: 015202111

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2023

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 cleaning chemicals, knife, hammer, thumb tacks unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2023
Plan of Correction
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Administrator locked all chemicals and objexts unsafe for clients during the visit. Deficiency is cleared.
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:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2023


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 08/25/2023 01:44 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 08/25/2023 at 12:20 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 - OLYMPIAD
FACILITY NUMBER: 015202111

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 back exit gates function properly which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2023
Plan of Correction
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Administrator will get the side gates fixed to function efftively and submit video proof by POC date.
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

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 broken window screen which poses/posed a potenti al health, safety or personal rights risk to persons in care. One client room is missing a window screen.
POC Due Date: 09/01/2023
Plan of Correction
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Administrator will install window screens in good conditon and submit photo proof to CCL 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:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2023


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Page: 4 of 7
Document Has Been Signed on 08/25/2023 01:44 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 08/25/2023 at 12:20 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 - OLYMPIAD
FACILITY NUMBER: 015202111

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 box of medicine in the front area which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2023
Plan of Correction
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Administrator locked away the box of medicines during visit. Deficiency is cleared.
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:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2023


LIC809 (FAS) - (06/04)
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