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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 02:56:05 PM

Document Has Been Signed on 07/31/2024 02:56 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:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Adrian Yanga, Interim AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 7/31/2024 at 1:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to death report received on 6/30/2024. LPA met with Interim Administrator, Adrian Yanga and explained the purpose of the visit.

LPA received death report on 6/30/2024 for client (C1). Death report revealed that C1 passed away on 6/29/2024 due to Acute Respiratory Failure. C1 was under hospice care.

LPA interviewed 1 staff and obtained documents (C1's care notes). C1 was admitted to hospice care on 6/18/2024.


No deficiencies is 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: 07/31/2024
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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