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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200719
Report Date: 10/09/2024
Date Signed: 10/09/2024 11:52:33 AM

Document Has Been Signed on 10/09/2024 11:52 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/
DIRECTOR:		TEKLE, SOPHIAFACILITY TYPE:
734
ADDRESS:1805 SMOKE BELLEW RDTELEPHONE:
(925) 495-4948
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 5CENSUS: 4DATE:
10/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Sophia Tekle, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:05 PM
NARRATIVE
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On 10/9/2024 at 8:50AM, Licensing Program Analysts (LPAs) G. Luk and P. Manalo arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Administrator, Sophia Tekle and explained the purpose of the visit.

LPAs toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. Smoke and carbon monoxide combination 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 113.2 degrees F in the hallway bathroom. 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 9/14/2024.

LPAs reviewed 4 clients and 5 staff files starting at 9:05AM. LPAs reviewed client's P & I money with logs. LPAs interviewed 2 staff starting at 10:00AM. LPA reviewed a sample of client's medications during inspection.

At 9:20AM, LPAs observed both facility side gates were locked. Staff removed locks during inspection. Civil penalty of $500 is being assessed.

At 11:00AM, LPAs observed S2 does not have health screening on file.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. A copy of this report, civil penalty, and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 10/09/2024 11:52 AM - It Cannot Be Edited


Created By: Grace Luk On 10/09/2024 at 11:28 AM
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: 10/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

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 locking both side gates without fire clearance for locked parameter which poses an immediate health and safety risk to persons in care.
POC Due Date: 10/10/2024
Plan of Correction
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Staff removed locks during inspection. Deficiency cleared.

Civil penalty of $500 is being assessed.
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: 10/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/09/2024 11:52 AM - It Cannot Be Edited


Created By: Grace Luk On 10/09/2024 at 11:28 AM
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: 10/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

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 not having health screening completed for S2 which poses a potential health and safety risk to persons in care.
POC Due Date: 10/31/2024
Plan of Correction
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Administrator has agreed to obtain health screening for S2 and submit a copy 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: 10/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3