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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200720
Report Date: 01/24/2025
Date Signed: 01/24/2025 11:30:06 AM

Document Has Been Signed on 01/24/2025 11:30 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 - TRAVISOFACILITY NUMBER:
019200720
ADMINISTRATOR/
DIRECTOR:		TEKLE, SOPHIAFACILITY TYPE:
734
ADDRESS:722 TRAVISO CIRTELEPHONE:
(925) 292-5742
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 4CENSUS: 3DATE:
01/24/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Sophia Tekle, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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On 1/24/2025 at 9:40AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to death report received on 1/19/2025. LPA met with Administrator, Sophia Tekle and explained the purpose of the visit.

Death report revealed that C1 passed away at the hospital on 1/19/2025 due to acute GI bleeding. C1 was admitted to the hospital on 1/13/2025 for possible pneumonia.


LPA interviewed staff and reviewed documents including C1's physician's report, doctor's visit report, and facility notes. C1 had a history of GI bleeding. C1 was sent to the hospital on 1/13/2025 due to low grade fever and possible pneumonia. Staff was communicating with ICU nurse on a regular basis regarding C1's condition. C1 had GI bleeding while at the hospital and blood transfusion was done. Hospital called the facility on 1/19/2025 to inform staff of C1's passing.


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: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2025
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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