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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200719
Report Date: 04/07/2023
Date Signed: 04/07/2023 10:16:30 AM

Document Has Been Signed on 04/07/2023 10:16 AM - 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: 4DATE:
04/07/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Sophia Tekle, AdministratorTIME COMPLETED:
10:25 AM
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On 4/7/2023 at 9:05AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to death report received on 4/6/2023. LPA met with Nurse, Tiruwork Guangul and explained the purpose of the visit. Administrator, Sophia Tekle arrived 40 minutes later.

LPA received death report on 4/6/2023 for client (C1). Death report revealed that C1 passed away at the hospital on 4/6/2023 due to acute respiratory failure and hypoxia.

LPA interviewed staff and obtained C1's care notes. LPA was informed that C1 sent out to the hospital on 3/19/2023 due to low oxygen level. C1's family and doctor was notified. Facility staff went to the hospital and provided assistance with ADL (Activities of Daily Living) care for C1. Family contacted the facility and informed administrator that C1 passed away on 4/6/2023.

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: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2023
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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