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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015202111
Report Date: 11/28/2023
Date Signed: 11/28/2023 04:04:54 PM

Document Has Been Signed on 11/28/2023 04:04 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:
11/28/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Mario RodriguezTIME COMPLETED:
04:25 PM
NARRATIVE
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On this day at around 3:15 PM, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct a case management visit. LPA was met by Remedios Sullera. LPA explained to Sullera the purpose of the visit. Administrator Mario Rodriguez was out of the facility and authorized Sullera to sign the report.

On October 31, 2023, LPA received six-month review of the facility from Department of Developmental Services (DDS) Nurse Consultant indicating that the facility failed to assist two clients to complete routine laboratory tests as ordered by the doctor.

Deficiency is cited per Title 22 California Code of Regulations.

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: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/28/2023
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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Document Has Been Signed on 11/28/2023 04:04 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 11/28/2023 at 03:31 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: 11/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/30/2023
Section Cited
CCR
80075(a)

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80075 Health Related Services
(a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services.
This requirement is not met as evidenced
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Labs for the two clients have been completed on October 10, 2023 per Administrator. Deficiency is cleared during the visit.`
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by: Based on record review, Licensee did not comply with citation above by failing to make arrangement for two clients' routine lab tests as ordered by their doctor which poses an immediate health and safety risk to clients under care.
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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: 11/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023


LIC809 (FAS) - (06/04)
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