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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200458
Report Date: 07/28/2022
Date Signed: 07/28/2022 12:02:20 PM

Document Has Been Signed on 07/28/2022 12:02 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 - CHABLISFACILITY NUMBER:
019200458
ADMINISTRATOR:DAGUIO, MARILYN D.FACILITY TYPE:
734
ADDRESS:2654 CHABLIS WAYTELEPHONE:
(408) 558-1500
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 5CENSUS: 4DATE:
07/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Marilyn Daguio, AdministratorTIME COMPLETED:
12:15 PM
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On 7/28/2022 at 10:30AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to death report received on 7/22/2022. LPA met with Administrator, Marilyn Daguio.

Death report dated 7/22/2022 stated that C1 was sent to the hospital due to breathing heavy and fast, bluish tongue and fingernail beds on 7/12/2022. C1 was placed on antibiotic for sepsis and was placed on comfort care on 7/21/2022 at the hospital. C1 passed away at the hospital on 7/22/2022.

During visit, LPA interviewed S1 and was informed that C1 was sent to the hospital on 7/11/2022. LPA verified on facility notes that C1 was sent to the hospital on 7/11/2022. LPA advised Administrator to update death report and resubmit it to CCLD. LPA reviewed C1's file and observed C1 has a primary diagnosis of chronic respiratory failure. Facility notes indicated that S2 observed C1 breathing heavy and S2 called 911. Paramedics arrived shortly after and took C1 to the hospital. C1 passed away at the hospital.


No deficiencies are being cited on this date.

Exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2022
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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