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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015202141
Report Date: 02/10/2024
Date Signed: 02/10/2024 02:28:02 PM

Document Has Been Signed on 02/10/2024 02:28 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 - MONTECITOFACILITY NUMBER:
015202141
ADMINISTRATOR:DESIREE R. FREDELUCESFACILITY TYPE:
734
ADDRESS:36743 MONTECITO DRTELEPHONE:
(510) 494-9050
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 5CENSUS: 5DATE:
02/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:ELIZABETH BRYANT, LVNTIME COMPLETED:
03:25 PM
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At approximately 9:40AM, Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to conduct a Required 1 Year annual inspection and met with Staff Member, Elizabeth Bryant, LVN. Facility has an approved fire clearance for five (5) bedridden residents for a total capacity of five (5) residents.

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 3 of 5 resident records which were all complete. LPA also reviewed 4 staff files which were found to be organized with proper documentation.

Administrator's 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 01/01/2024. Facility's fire extinguishers were last inspected 12/14/2023. Smoke detectors and carbon monoxide detectors were tested and operational. 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: 02/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2024
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 02/10/2024 02:28 PM - It Cannot Be Edited


Created By: Carol Fowler On 02/10/2024 at 01:26 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 - MONTECITO
FACILITY NUMBER: 015202141

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2024

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 by having cleaning solutions such as boa floor cleaner, Clorox, paint, Lysol, clean side wipes, frebreeze, and windex unlocked and accessible to residents which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/11/2024
Plan of Correction
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Administrator agreed to keep cleaning supplies locked in a locked cabinet. DEFICIENCY CLEARED DURING 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:Bennett Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2024


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 - MONTECITO
FACILITY NUMBER: 015202141
VISIT DATE: 02/10/2024
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Continued from LIC809

LPA observed the following deficiencies:

· At 11:25AM, LPA observed boa floor cleaner, Clorox, paint, Lysol, clean side wipes, frebreeze, and windex unlocked.

LPA conducted staff interviews, 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, 02/16/2024.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC-809 & 809C, LIC-809D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2024
LIC809 (FAS) - (06/04)
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