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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200604
Report Date: 02/23/2023
Date Signed: 02/23/2023 04:54:33 PM

Document Has Been Signed on 02/23/2023 04:54 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:
02/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Connie VigoTIME COMPLETED:
05:00 PM
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On 02/23/2023 at 3:15 PM, Licensing Program Analyst (LPA) J. Sampair conducted an infection control annual inspection. Upon entry, LPA explained the purpose of the visit to Administrator (ADM) Connie Vigo. ADM and LPA toured 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 visitor's log, sanitizer, face masks, and no touch thermometer. Facility follows daily cleaning, sanitation of frequently touched common surfaces with disinfectants. COVID-19 signs were posted.

The LIC 610D Emergency/Disaster plan was in the Disaster Plan binder. Centrally stored medications were in locked cabinets. The temperature inside of the facility was 73.0 and the hot water was 109 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 extinguishers were fully charged and had been serviced within one (1) year. To fulfill their duties oversee business operations, an administrator is on site at least 20 hours each week.

ADM will send updated copies of these documents to CCL on or before 03/02/2023:

· LIC500 - Personnel Report
· LIC308 - Designation of Facility Responsibility
· 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: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2023
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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