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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200594
Report Date: 05/03/2024
Date Signed: 05/03/2024 05:29:53 PM

Document Has Been Signed on 05/03/2024 05:29 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ELWYN CALIFORNIA - CAMINO SOLANOFACILITY NUMBER:
079200594
ADMINISTRATOR/
DIRECTOR:		ANGEL, LOURDES DFACILITY TYPE:
734
ADDRESS:1194 CAMINO SOLANOTELEPHONE:
(408) 558-1500
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY: 4CENSUS: 4DATE:
05/03/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Lourdes Angel, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
NARRATIVE
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On 05/03/2024 at 3:30PM, Licensing Program Analyst (LPA) Lori Alexander conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 04/04/2024. LPA met with Administrator, Lourdes Angel and explained the purpose of the visit.

LPA L. Alexander interviewed, Administrator, Lourdes Angel, for further details with the incident that took place with R1 on 04/04/2024. Lourdes stated that on 04/04/2024 she discovered that R1 did not receive their injection for diagnosis Osteoporosis (M81.0). Lourdes stated that the discovery came when she was preparing for the IHCP meeting which is a treament meeting and that she confirmed with staff (nurses) that all clients' had their due treatment. Lourdes stated that all the notes were available except for R1 was missing the notes. Lourdes stated that she called the clinic and that the clinic advised that R1 did not receive injection which was, Prolia 60mg, which is given every 6 months due to R1 not getting their labs completed first. Lourdes stated that labs are done prior to the injection to see if the patient's calcium levels are at the required range in order to receive this type of injection for osteoporosis. LPA reviewed R1's Physician's Report which was signed and dated by physician on 02/11/2024. LPA reviewed that R1's last Prolia injection was 06/02/23 per Camino Solano Home Consultation Communication Note prior to the missed appointment. LPA reviewed that R1 had current Prolia injection on 04/18/2024.

LIC809-C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ELWYN CALIFORNIA - CAMINO SOLANO
FACILITY NUMBER: 079200594
VISIT DATE: 05/03/2024
NARRATIVE
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LIC809-C Continued...

Lourdes further stated that there was a breakdown in communication. Lourdes stated that the nurse from the registry received the reminder from the endocrinology clinic and did not communicate the appointment reminder. Lourdes stated that when the staff nurse took R1 for injection appointment that they were turned away at the clinic because the labs were not completed. Lourdes stated that the registry nurse did not leave the notes nor did they communicate with anyone of the reminder.

The following deficiencies were cited (See LIC809D) from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/03/2024 05:29 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 05/03/2024 at 04:43 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 - CAMINO SOLANO
FACILITY NUMBER: 079200594

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/10/2024
Section Cited
CCR
80061(b)

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Reporting Requirements
Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.

This requirement is not met as evidenced by:
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Administrator will self-certify that they read and understand the regulation and submit to CCLD by POC due date.
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Based on interview and record review, the licensee did not comply with the section cited above for not reporting the incident to CCLD in a timely manner which poses a potential health and safety risk to persons in care.
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Type B
05/10/2024
Section Cited
CCR80078(a)

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Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement is not met as evidenced by:
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Administrator will self-certify that they read and understand the regulation. In addition, the administrator will also do an In-Training with all Staff Nurses regarding medication errors with proper protocols and procedures and send list of participants to CCLD by POC due date.
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Based on interview and record review, the licensee did not comply with the section cited above by not evaluating the client's (R1's) higher level of care needs which includes constant review of care needs and medical records which poses a potential health and safety risk to persons in care.
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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:Bennett Fong
LICENSING EVALUATOR NAME:Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024


LIC809 (FAS) - (06/04)
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