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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200458
Report Date: 07/27/2023
Date Signed: 07/27/2023 05:52:55 PM

Document Has Been Signed on 07/27/2023 05:52 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:
07/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jennifer Gilley, AdministratorTIME COMPLETED:
06:10 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
On 7/27/2023 at 1:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Administrator, Jennifer Gilley and explained the purpose of the visit. The facility’s fire clearance was approved for 5 bedridden clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. Smoke and carbon monoxide detectors were observed. Smoke detectors are interconnected with sprinklers system. Fire extinguishers were observed to be full and last serviced on 7/26/2023. One week of non-perishable and 2-day perishable food supplies were sufficient. Hot water temperature was measured at 120 degrees F in the kitchen sink. All client bedrooms have automatic hoyer lifts and bathroom have hoyer lift installed. Medications were in a locked in kitchen cabinets. Cleaning supplies and toxins were locked and stored appropriately and inaccessible to clients. First Aid kit is complete. No bodies of water observed. Indoor and outdoor passageways were free of obstruction. Last fire drill was conducted on 7/23/2023.

LPA reviewed 4 clients and 4 staff files starting at 2:00PM. LPA reviewed client's P & I money with logs. LPA interviewed 2 staff and attempted interviews with 2 clients starting at 4:50PM. LPA reviewed a sample of client's medications starting at 5:15PM.

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: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2023
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