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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015202141
Report Date: 01/31/2025
Date Signed: 01/31/2025 12:35:53 PM

Document Has Been Signed on 01/31/2025 12:35 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:
01/31/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Desiree Fredeluces, Administrator TIME VISIT/
INSPECTION COMPLETED:
12:50 PM
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On 01/31/2025 at 9:00AM, Licensing Program Analyst (LPA) Patricia Manalo arrived unannounced to conduct a Required 1 Year Inspection. DDS Nurse Consultant Joyce Singh arrived with LPA. LPA met with Licensing Vocational Nurse, Edward Falaam, who phoned the Administrator and explained the purpose of the visit. Administrator, Desiree Fredeluces, arrived shortly after. The fire clearance is approved for five (5) all may be bedridden.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms which all bedrooms are occupied by the clients. There are no bodies of water. A comfortable temperature for clients is maintained at 69 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature was measured at 118.2 degree Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygiene's was available for clients. There is a minimum of one week supply of nonperishable and 2-day perishables food supply.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 12/05/2024. Emergency Disaster Drill was last posted on 01/24/2025. Emergency Disaster Plan was last posted 01/10/2025. First aid kit was observed to be complete.

At 9:58 AM, 5 of clients records were reviewed. At 10:36 AM, 4 staff records were reviewed and 4 of 4 have current first aid training and are associated to the facility. LPA reviewed client's P&I money with log and there was no discrepancies observed. LPA reviewed a sample of client's medications. All records were observed to be complete and up to date.

Continue to LIC809-C...
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ELWYN NC - MONTECITO
FACILITY NUMBER: 015202141
VISIT DATE: 01/31/2025
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 02/10/2025:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610 Emergency Disaster Plan
Auto Insurance
Auto Registration

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

AT 9:19 AM, LPAs observed that the side gate has a second latch from the inside. Civil penalty of $500 is being assessed.

At 9:27 AM, LPA observed a step ladder blocking the garage door passageway.

At 11:30 AM, LPAs observed that C1 and C2 did not have their PRN medications at the facility.


The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/31/2025 12:35 PM - It Cannot Be Edited


Created By: Patricia Manalo On 01/31/2025 at 12:00 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: 01/31/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above by having the side gate without fire clearance for locked parameter which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/01/2025
Plan of Correction
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2
3
4
Administrator removed the locks during the visit. Deficiency cleared during the visit.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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4
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:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/31/2025 12:35 PM - It Cannot Be Edited


Created By: Patricia Manalo On 01/31/2025 at 12:00 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: 01/31/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

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 a step ladder blocking the garage door passageway which poses a potential health and safety risk to persons in care.
POC Due Date: 02/01/2025
Plan of Correction
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Staff removed the ladder from the passageway. Deficiency cleared during the visit.
Type B
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

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 not having C1 and C2's PRN medication in the facility which poses a potential health and safety risk to persons in care.
POC Due Date: 02/14/2025
Plan of Correction
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Staff agrees to order the PRN medication for the clients to have at the facility and send proof to CCLD.
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:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2025


LIC809 (FAS) - (06/04)
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