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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200719
Report Date: 09/23/2022
Date Signed: 09/23/2022 02:13:37 PM

Document Has Been Signed on 09/23/2022 02:13 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 CALIFORNIA - SMOKE BELLEWFACILITY NUMBER:
019200719
ADMINISTRATOR:TEKLE, SOPHIAFACILITY TYPE:
734
ADDRESS:1805 SMOKE BELLEW RDTELEPHONE:
(925) 495-4948
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 5CENSUS: 5DATE:
09/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Sophia Tekle, AdministratorTIME COMPLETED:
02:25 PM
NARRATIVE
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On 9/23/2022 at 11:55AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with LVN, Tiruwork Guangul and explained the purpose of the visit. Administrator, Sophia Tekle arrived 30 minutes later.

Upon entry, LPA's temperature was checked and COVID-19 questionnaire was asked. LPA completed visitor's log. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, living room, garage, and outdoor areas. LPA observed sign & symptoms, cough etiquette, and social distancing were posted in the common areas. Hand washing posters were posted at bathrooms and sinks.

During record review, LPA observed visitors log and temperature logs for clients and staff. LPA observed facility has a copy of Mitigation Plan on file. LPA observed facility staff completed fit testing for N95 respirator and documentation of certificates. LPA observed PPEs, food, and paper supplies are sufficient.

At 12:15PM, LPA observed unlocked lighters in the kitchen drawers. Staff locked up the lighters during inspection.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiency by POC date may result in additional 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: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2022
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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Document Has Been Signed on 09/23/2022 02:13 PM - It Cannot Be Edited


Created By: Grace Luk On 09/23/2022 at 02:03 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 CALIFORNIA - SMOKE BELLEW
FACILITY NUMBER: 019200719

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 by having unlocked lighters in the kitchen drawer which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/24/2022
Plan of Correction
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Staff locked up lighters during inspection.

Deficiency cleared.
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: 09/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2022


LIC809 (FAS) - (06/04)
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