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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200720
Report Date: 09/26/2023
Date Signed: 09/26/2023 01:11:15 PM

Document Has Been Signed on 09/26/2023 01:11 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: 4DATE:
09/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Sophia Tekle, AdministratorTIME COMPLETED:
01:25 PM
NARRATIVE
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On 9/26/2023 at 8:55AM, 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 4 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 110.1 degrees F in the kitchen sink. All client bedrooms have automatic hoyer lifts and bathroom have hoyer lift installed. Cleaning supplies and toxins were locked and stored appropriately and inaccessible to clients. First Aid kit is complete. Last fire drill was conducted on 9/6/2023.

LPA reviewed 4 client and 3 staff files starting at 9:30AM. LPA reviewed client's P & I money with logs. LPA interviewed 2 staff and attempted interviews with 2 clients starting at 12:00PM. LPA reviewed a sample of client's medications starting at 11:34AM.

At 9:20AM, LPA observed unlocked of overflow medications and treatments in the kitchen cabinet. Administrator locked up the cabinet during inspection.

At 11:50AM, LPA observed centrally stored medication records was missing some medications that the clients was taking.

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 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: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2023
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 09/26/2023 01:11 PM - It Cannot Be Edited


Created By: Grace Luk On 09/26/2023 at 12:42 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 - TRAVISO
FACILITY NUMBER: 019200720

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 overflow medications unlocked and accessible which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/27/2023
Plan of Correction
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Administrator locked up the cabinet 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: 09/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/26/2023 01:11 PM - It Cannot Be Edited


Created By: Grace Luk On 09/26/2023 at 12:42 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 - TRAVISO
FACILITY NUMBER: 019200720

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(7)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:

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 completing the centrally stored records which poses a potential health and safety risk to persons in care.
POC Due Date: 10/20/2023
Plan of Correction
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Administrator has agreed to review the client's centrally stored records. Administrator will submit a completed sample and self-certification to CCLD by POC date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
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: 09/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2023


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