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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200719
Report Date: 09/12/2023
Date Signed: 09/12/2023 05:20:14 PM

Document Has Been Signed on 09/12/2023 05:20 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: 3DATE:
09/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Sophia Tekle, AdministratorTIME COMPLETED:
05:30 PM
NARRATIVE
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On 9/12/2023 at 12:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Administrator, Sophia Tekle 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. One week of non-perishable and 2-day perishable food supplies were sufficient. Hot water temperature was measured at 107.2 degrees F in the hallway bathroom sink. All client bedrooms have automatic hoyer lifts and bathroom have hoyer lift installed. Medications were locked in a medication cart. 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 8/14/2023.

LPA reviewed 3 client and 3 staff files starting at 1:06PM. LPA reviewed client's P & I money with logs. LPA interviewed 2 staff and attempted interviews with 2 clients starting at 4:20PM. LPA reviewed a sample of client's medications starting at 3:45PM.

At 4:00PM, LPA observed C1 had a PRN doctor's order for Milk of Magnesia. However, facility does not have the medication in stock. LPA was informed that C1 has not used the PRN in a few months and last Milk of Magnesia expired in July 2023. LPA observed doctor's order for C1's sunscreen was for SPF 30, but facility has been giving C1 sunscreen SPF 50.

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: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2023
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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Document Has Been Signed on 09/12/2023 05:20 PM - It Cannot Be Edited


Created By: Grace Luk On 09/12/2023 at 04:52 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: 09/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not having C1's Milk of Magnesia and not having doctor's order of SPF for C1's sunscreen which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/13/2023
Plan of Correction
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Administrator has agreed to obtain a new doctor's order for sunscreen SPF 50 and discontinue order for Milk of Magnesia. Administrator will submit new doctor's order 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: 09/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2023


LIC809 (FAS) - (06/04)
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