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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200604
Report Date: 08/17/2022
Date Signed: 08/17/2022 01:37:58 PM

Document Has Been Signed on 08/17/2022 01:37 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 - BANBURYFACILITY NUMBER:
079200604
ADMINISTRATOR:CONCEPCION VIGOFACILITY TYPE:
734
ADDRESS:2308 BANBURY PLACETELEPHONE:
(925) 378-7948
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 5CENSUS: 5DATE:
08/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Rigill LiboroTIME COMPLETED:
02:00 PM
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On 8/17/22 at 11:45 AM, Licensing Program Analyst (LPA) J. Sampair conducted an infection control annual inspection. Upon entry, LPA explained the purpose of the visit with staff member Rigill Liboro. Administrator Connie Vigo was not able to meet the LPA, though they spoke over the phone about infection control and with Rigill Liboro, he toured the facility inside and outside.

Facility has an infection control plan in place that they are following. The designated infection control leader is the administrator. They have one central entry point that has been designated for universal entry screening with the station located near the front entrance with visitor's log, hand sanitizer, face masks, and no touch thermometer. Facility follows daily cleaning, sanitation of frequently touched common surfaces with disinfectants. COVID-19 signs were posted to promote hand washing, cough/sneeze etiquette and physical distancing.

A written Emergency/Disaster plan was in the Disaster Plan binder, though it was the old version. Centrally stored medications were in locked cabinets. The temperature inside of the facility was 78.6 and the hot water was 110 degrees Fahrenheit, both of which were in the safe range. Toxic chemicals and sharp objects were stored in locked closets and cabinets. Carbon monoxide and smoke detectors were fully functional and the fire extinguisher had been serviced within one (1) year and it was fully charged. An administrator is on site more than the required 20 hour minimum each week to oversee business operations.

Continues on LIC 809-C . . .
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2022
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 - BANBURY
FACILITY NUMBER: 079200604
VISIT DATE: 08/17/2022
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. . . Continued from LIC 809

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 08/24/22:

· LIC500 - Personnel Report
· LIC308 - Designation of Facility Responsibility
· LIC610E - Emergency/Disaster Plan
· Evidence of Liability Insurance & Surety Bond

No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided via email.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022
LIC809 (FAS) - (06/04)
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