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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200458
Report Date: 07/31/2024
Date Signed: 07/31/2024 02:54:32 PM

Document Has Been Signed on 07/31/2024 02:54 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/
DIRECTOR:		DAGUIO, MARILYN D.FACILITY TYPE:
734
ADDRESS:2654 CHABLIS WAYTELEPHONE:
(408) 558-1500
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 5CENSUS: 4DATE:
07/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Adrian Yanga, Interim AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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On 7/31/2024 at 10:30AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Interim Administrator, Adrian Yanga 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 4/10/2024. One week of non-perishable and 2-day perishable food supplies were sufficient. Hot water temperature was measured at 105 degrees F in the hallway bathroom 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. Last disaster drill was conducted on 7/9/2024.

LPA reviewed 4 clients and 3 staff files starting at 11:30AM. LPA reviewed client's P & I money with logs. LPA interviewed 2 staff and attempted interviews with 2 clients starting at 1:00PM. LPA reviewed a sample of client's medications during inspection.

At 12:00PM, LPA reviewed client's P & I money with logs and observed two out of four clients had P & I money deducted for items that was not for the clients. LPA observed C1 and C3 was charged for food items and/or parking fees. Both clients have G-tube feeding and did not consume the food items that was purchased.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties.
Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2024
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 07/31/2024 02:54 PM - It Cannot Be Edited


Created By: Grace Luk On 07/31/2024 at 02:35 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 - CHABLIS
FACILITY NUMBER: 019200458

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(f)
(f) The licensee or employee of a licensee shall not make expenditures from clients' cash resources for any basic services in these regulations, or for any basic services identified in a contract/admission agreement between the client and the licensee.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by using client's P & I money for food items and parking which poses a potential personal rights violation to persons in care.
POC Due Date: 08/14/2024
Plan of Correction
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Interim Administrator (IA) has agreed to correct the P & I log and give the money back to the two clients. IA will submit copies of the receipts and updated P & I logs to CCLD by POC date.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2024


LIC809 (FAS) - (06/04)
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