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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015202141
Report Date: 01/22/2025
Date Signed: 01/22/2025 12:33:13 PM

Document Has Been Signed on 01/22/2025 12:33 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ELWYN NC - MONTECITOFACILITY NUMBER:
015202141
ADMINISTRATOR/
DIRECTOR:		DESIREE R. FREDELUCESFACILITY TYPE:
734
ADDRESS:36743 MONTECITO DRTELEPHONE:
(510) 494-9050
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 5CENSUS: 5DATE:
01/22/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:25 AM
MET WITH:Cherry Sibal, House ManagerTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
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
On 01/22/2025 at 11:25 AM, Licensing Program Analysts (LPAs) P.Manalo and L. Fontanilla conducted an unannounced Case Management visit regarding a self-reported incident report abuse dated 01/13/2025. LPAs met with Staff, Elizabeth Bryant, who phoned the Administrator and House Manager, and explained the purpose of the visit. Administrator came shortly after.

LPAs obtained the following documents such as the ID Face Sheet, the Police Deputy Contact Information, Physician's Report, SOC341, IPP, Behavioral Consultant Initial Assessment, and Special Incident Reports.

The incident was reported to San Leandro Police Department. LPAs requested to have the police report sent to CCLD once available.

Based on record review, IPP indicated that client (C1) was placed in a subacute prior to admission to the facility in November 2024.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2025
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 1