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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200720
Report Date: 09/25/2024
Date Signed: 09/25/2024 01:53:32 PM

Document Has Been Signed on 09/25/2024 01:53 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/
DIRECTOR:		TEKLE, SOPHIAFACILITY TYPE:
734
ADDRESS:722 TRAVISO CIRTELEPHONE:
(925) 292-5742
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 4CENSUS: 4DATE:
09/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Sophia Tekle, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:50 PM
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On 9/25/2024 at 9:30AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with RN, Olivia Hwang and explained the purpose of the visit. Administrator, Sophia Tekle arrived 30 minutes later.

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 and last serviced on 10/2/2023. One week of non-perishable and 2-day perishable food supplies were sufficient. Hot water temperature was measured at 114.3 degrees F in the kitchen sink. All client bedrooms have automatic hoyer lifts and bathroom have hoyer lift installed. First Aid kit is complete. Last fire drill was conducted on 9/5/2024.

LPA reviewed 4 clients and 5 staff files starting at 10:20AM. LPA reviewed client's P & I money with logs. LPA interviewed 2 staff at around 12:00PM. LPA reviewed a sample of client's medications during inspection.

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: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2024
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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