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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200600
Report Date: 10/25/2024
Date Signed: 10/25/2024 01:45:02 PM

Document Has Been Signed on 10/25/2024 01:45 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 - VIA DEL VERDESFACILITY NUMBER:
079200600
ADMINISTRATOR/
DIRECTOR:		HUFALAR, DESIREE BFACILITY TYPE:
734
ADDRESS:1736 E VIA DEL VERDESTELEPHONE:
(408) 558-1500
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY: 5CENSUS: 4DATE:
10/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:50 AM
MET WITH:Rosemarie Linodogan, Caregiver/RNTIME VISIT/
INSPECTION COMPLETED:
01:55 PM
NARRATIVE
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On 10/25/2024 at 11:50am, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct required annual inspection. LPA met with Rosemarie Linodogan, Caregiver/RN. Administrator, Desiree Hufalar arrived at 12:10pm and LPA explained the purpose of the visit. The facility’s fire clearance was approved for five (5) Bedridden clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of five (5) bedrooms and two (2). All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 70 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 120.0 degrees Fahrenheit. All toilets, hand washing stations, and bathing stations are safe, sanitary and in operating condition. LPA observed a supply of extra hygiene items for clients. There is a minimum of 7 day supply of non-perishables and 2 day perishables food supply.

Fire extinguisher was last serviced on 03/5/2024. Emergency Disaster Drill was last conducted on 10/22/2024. Fire drill was last conducted on 09/30/2024. First aid kit was observed to be complete.

Report continues on LIC809.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ELWYN CALIFORNIA - VIA DEL VERDES
FACILITY NUMBER: 079200600
VISIT DATE: 10/25/2024
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Continued from LIC809.

Four (4) staff records and four (4) client records were reviewed, current, and complete. LPA also reviewed P & I.

The following forms to be updated and submitted to CCLD by 11/1/2024:
  • LIC610D Emergency disaster plan (last page)
  • Surety Bond
  • LIC500 (Personnel Record)
  • LIC308 (Designation of facility Responsibility)
  • LIC400 Affidavit Regarding Client/Resident Cash Resources


LPA observed the following deficiency:

At 12:05pm, LPA observed unlocked kitchen cabinet located underneath the sink with disinfectants.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of the appeal rights and this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/25/2024 01:45 PM - It Cannot Be Edited


Created By: Laura Hall On 10/25/2024 at 01:33 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 - VIA DEL VERDES
FACILITY NUMBER: 079200600

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having bottles of disinfectant in unlocked cabinet underneath kitchen sink which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2024
Plan of Correction
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Caregiver immediately locked cabinet. Deficiency cleared during visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2024


LIC809 (FAS) - (06/04)
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