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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015202111
Report Date: 09/05/2024
Date Signed: 09/05/2024 03:02:29 PM

Document Has Been Signed on 09/05/2024 03:02 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/
DIRECTOR:		MARIO P. RODRIGUEZFACILITY TYPE:
734
ADDRESS:32744 OLYMPIAD CTTELEPHONE:
(510) 475-5532
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 5CENSUS: 4DATE:
09/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:05 AM
MET WITH:Remedios SulleraTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On this day at around 10:05 am, Licensing Program Analysts (LPAs) Luisa Fontanilla and Patricia Manalo arrived unannounced to conduct annual required inspection. LPAs met with the Administrator Remedios Sullera. LPAs explained to Sullera the purpose of the visit.

During the visit, LPAs inspected the facility inside and out including but not limited to client rooms, bathrooms, kitchen, garage, backyard. There were 4 clients, 2 LVNs, 1 CNA and 1 staff from Vistability observed.

The facility has an approved fire clearance for 5 non ambulatory clients. Multiple fire extinguishers that appeared full and has tag date of 1/24/24 were observed. Carbon monoxide was tested and observed operational. The last inspection of smoke detectors was conducted on 4/25/2023 by Hue & Cry Inc..
Last fire drill was conducted on 8/25/24 and last earthquake drill was done on 8/14/24. Generator was tested on 9/3/24. First aid was observed complete.

At around 11 am, LPAs reviewed 4 client and 4 staff files. At 1:30 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.

At 11:15 am, LPAs observed scissors unlocked in a drawer. At around 11:30am, LPAs observed a box of chemicals in the backyard unlocked.

Deficiency is cited per Title 22 California Code of Regulations (refer to Lic 809D).

Exit interview was conducted with Sullera and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2024
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 2
Document Has Been Signed on 09/05/2024 03:02 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 09/05/2024 at 02:32 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: 09/05/2024

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 chemicals and scissors unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2024
Plan of Correction
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This deficiency is cleared during the visit.
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: 09/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024


LIC809 (FAS) - (06/04)
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