079200601-8-10-2023-15-AS-JCCR-CUKQ94-20230810115742

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200601
Report Date: 08/10/2023
Date Signed: 08/10/2023 11:57:46 AM

Document Has Been Signed on 08/10/2023 11:57 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 - MARIA		FACILITY NUMBER:	079200601
ADMINISTRATOR:	HUFALAR, DESIREE B		FACILITY TYPE:	734
ADDRESS:	1364 MARIA AVE		TELEPHONE:	(925) 483-2792
CITY:	CONCORD	STATE: CA	ZIP CODE:	94518
CAPACITY: 4		CENSUS: 4	DATE:	08/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Desiree Hufalar, Administrator		TIME COMPLETED:	12:10 PM

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On 08/10/2023 at 09:05 am Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to do an annual inspection. LPA meet with Administrator Desiree Hufalar and explained the purpose of the visit.

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. One week of non-perishable and 2-day perishable food supplies were sufficient. All client bedrooms have automatic hoyer lifts and bathroom have hoyer lift. Medications were in a locked in 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 5 staff files starting at 10:05AM 5 of 5 staff were fingerprint cleared and associated to the facility. LPA reviewed client's P & I money with logs.

The following deficiency was observed during the visit:

The residents P&I logs were not accurate for three out of four residents

The Facility was cited, and citations can be found on the LIC 809-D. Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

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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Document Has Been Signed on 08/10/2023 11:57 AM - It Cannot Be Edited

Created By: Jill Clancy-Czuleger On 08/10/2023 at 11:43 AM

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 - MARIA	FACILITY NUMBER: 079200601
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80026(h)

Safeguards for Cash Resources, Personal Property and Valuables

(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by having three out of four residents P&I logs inaccurate and not matching the amount of money each resident had, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/14/2023
	Plan of Correction
1 2 3 4	Logs were corrected during visit. The facility agrees to review the regulations and submit a written statement of how they will accurately log the residents money. Proof of correction will be sent to CCLD by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Jill Clancy-Czuleger

LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

LIC809 (FAS) - (06/04)

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