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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200634
Report Date: 12/14/2021
Date Signed: 12/14/2021 02:58:41 PM

Document Has Been Signed on 12/14/2021 02:58 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 - TERRA VERDEFACILITY NUMBER:
079200634
ADMINISTRATOR:STEVENS, STACIFACILITY TYPE:
737
ADDRESS:2934 TERRA VERDE LNTELEPHONE:
(925) 418-4168
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 4CENSUS: 3DATE:
12/14/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Staci StevenTIME COMPLETED:
03:20 PM
NARRATIVE
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On 12/14/2021 Licensing Program Analyst (LPA) Leslie Ibo conducted an unannounced case management visit regarding a self reported incident, R1 received expired medication from August 2021 – October 2021, medication was given by staff six times. LPA explained the purpose of the visit with Administrator Staci Stevens.

LPA interviewed Administrator, at around 1:00PM. On November 3, 2021 Administrator came back from leave and was checking the residents medications and found out that staff gave expired medication to R1. Administrator admitted that 4 staff gave expired medication to R1, the medication was given 6x. Medication Hydrocodone was given to R1 6x after it was expired on August 2021. Per Administrator the resident's was checked and monitored for any unusual signs and symptoms from medication, and physician was informed as soon as the incident was found, medication was destructed on 11/3/2021. LPA interviewed S2 & S3 and admitted that expired medication was given to R1.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in Civil Penalties.

Exit interview conducted with Administrator. Copy of report and appeal rights was given to Administrator.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2021
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 12/14/2021 02:58 PM - It Cannot Be Edited


Created By: Leslie Ibo On 12/14/2021 at 02:27 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 - TERRA VERDE
FACILITY NUMBER: 079200634

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/14/2021
Section Cited
CCR
80075(b)(5)(B)

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(b) Clients shall be assisted as needed...(5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication… (B) Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met:
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Administrator will need to review all residents medication. Administrator need to create a document which all resident medication is listed,including but not limited to the following information : name of medication, dosage, times given, ordered date and EXPIRATION.
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Based on interview & records review the licensee failed to ensure R1 receive unexpired medication, Adminsitrator self reported that S2, S3, S4 & S5 gave R1 expired medication for 6X, which poses a immediate health and safety risk to residents in care.
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Administrator also needs to train all staff on medication process, topics of the training and staff signature is required to be sent to CCL office by 12/20/2021.

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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:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2021


LIC809 (FAS) - (06/04)
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