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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015202140
Report Date: 02/22/2024
Date Signed: 02/22/2024 12:43:44 PM

Document Has Been Signed on 02/22/2024 12:43 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 - CARNATIONFACILITY NUMBER:
015202140
ADMINISTRATOR:DESIREE R. FREDELUCESFACILITY TYPE:
734
ADDRESS:35649 CARNATION WAYTELEPHONE:
(510) 565-1916
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 4CENSUS: 4DATE:
02/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Estealla Turiano, LVNTIME COMPLETED:
01:30 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
At approximately 10:00AM, Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to conduct a Required 1 Year annual inspection and met with Staff Member, Estealla Turiano, LVN. Facility has an approved fire clearance for four (4) bedridden residents for a total capacity of four (4) residents. Administrator arrived at 11:35AM.

LPA conducted a tour of the facility and observed the following: the facility was clean and at a comfortable temperature with all exits free from obstruction. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. There is a sufficient supply of hygiene products, paper products, and linens available for resident use. Medication was centrally stored and secure.

LPA reviewed 4 of 4 resident records which were all complete. LPA also reviewed 4 staff files which were found to be organized with proper documentation.

Administrator Desiree Fredeluces Certificate (6054192735) was current with an expiration date of 01/10/2025.

LPA discussed facility's emergency and evacuation plan. The facility's last fire and evacuation drill was conducted 02/01/2024. Facility's fire extinguishers were last inspected 12/13/2023. Carbon monoxide detectors were tested and operational smoke detector and fire alarm was last serviced 2/1/2024. The amount of fresh and non-perishable foods are within regulation. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit.

Continued on LIC809C.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2024
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
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 - CARNATION
FACILITY NUMBER: 015202140
VISIT DATE: 02/22/2024
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
26
27
28
29
30
31
32
Continued from LIC809

Residents are non verbal.

LPA requested the following documents to update facility file:

· Designation of Facility Responsibility (LIC 308)
· Control of Property
· Emergency Disaster Plan (LIC 610D)
· Updated Personnel Report (LIC 500)
· Register of Clients/Residents (LIC 9020)
· Updated Liability Insurance

Facility Documents to be submitted to Community Care Licensing (CCL) by due date of Friday, 03/1/2024.

Exit interview conducted. Copy of this report provided. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2