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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200720
Report Date: 09/10/2021
Date Signed: 09/10/2021 04:07:56 PM

Document Has Been Signed on 09/10/2021 04:07 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 - TRAVISOFACILITY NUMBER:
019200720
ADMINISTRATOR:TEKLE, SOPHIAFACILITY TYPE:
734
ADDRESS:722 TRAVISO CIRTELEPHONE:
(925) 292-5742
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 4CENSUS: 3DATE:
09/10/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Sophia Tekle, AdministratorTIME COMPLETED:
04:21 PM
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On 9/10/2021 at 3:40PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with Administrator, Sophia Tekle and explained the purpose of the visit.

LPA received death report on 8/30/2021 for client (C1). Death report revealed that C1 passed away at the hospital on 8/29/2021.

Interview with S1 revealed that 911 was called on 8/8/2021 for C1 due to labored breathing. C1 was diagnosed with an infection and was treated at the hospital. C1 passed away at the hospital on 8/29/2021 due to acute/chronic respiratory failure.

LPA reviewed C1's physician's report and care notes. LPA observed that C1 has a diagnoses of COPD.

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: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2021
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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