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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200593
Report Date: 01/31/2025
Date Signed: 01/31/2025 12:06:12 PM

Document Has Been Signed on 01/31/2025 12:06 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/
DIRECTOR:		VIERNES, ADRIANFACILITY TYPE:
734
ADDRESS:1141 KEITH DRTELEPHONE:
(408) 558-1500
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY: 4CENSUS: 3DATE:
01/31/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Ritchie Villapando, Interim AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On 01/31/2025 at 09:30 AM Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct a Case Management. LPA met with with LVN Mylene Arthurs and explained the purpose of the visit. Interim Administrator Ritchie Villapando joined later.

LPA Received an email on 01/25/2025, From S1 stating that “I will be slowly transitioning out of my administrator role as of Monday”. This email did not disclose any additional information or state who would be fulfilling the role after Monday.

While at the facility S2 confirmed that S1 was no longer the administrator and S3 will be helping while they look for a new one. S3 was called and explained that S3 was working with administrators at the other homes and has assigned S4 to fill in while they look for a new administrator for this home.

Exit interview conducted. A copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2025
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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