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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200593
Report Date: 10/12/2023
Date Signed: 10/12/2023 02:21:06 PM

Document Has Been Signed on 10/12/2023 02:21 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 - KEITHFACILITY NUMBER:
079200593
ADMINISTRATOR:VIERNES, ADRIANFACILITY TYPE:
734
ADDRESS:1141 KEITH DRTELEPHONE:
(408) 558-1500
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY: 4CENSUS: 4DATE:
10/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:CaregiverTIME COMPLETED:
02:30 PM
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On 10/12/2023 at 11:40 am Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to do an annual inspection. LPA meet with caregiver Tinika Murphy and explained the purpose of the visit. Administrator Laurde Angel was called and agreed to have Tinika Murphy sign off on the report.

LPA inspected the facility inside out. There is no body of water. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. LPA inspected the living room, dining area, kitchen, bedrooms, hallways, bathrooms, side and backyards. Bedrooms were observed appropriately furnished with adequate lighting and drawers. One week of non-perishable and 2-day perishable food supplies were sufficient. Hot water temperature was measured at 120 degrees F in the kitchen sink. All client bedrooms have automatic hoyer lifts and bathroom have hoyer lift installed. Medications were in a locked in kitchen cabinets. Cleaning supplies and toxins were locked and stored appropriately and inaccessible to clients. Indoor and outdoor passageways were free of obstruction.


LPA reviewed 4 clients and 2 staff files starting at 12:00PM. LPA reviewed client's P & I money with logs. LPA reviewed a sample of client's medications starting at 2:15 PM.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2023
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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