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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200634
Report Date: 05/06/2022
Date Signed: 05/06/2022 01:03:06 PM

Document Has Been Signed on 05/06/2022 01:03 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:
05/06/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Rebecca Whitley, New AdministratorTIME COMPLETED:
11:35 AM
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On 5/5//2022 at 10:50AM, Licensing Program Analyst (LPA) L. Ibo conducted a health and safety check as a result of department receiving a priority 2 complaint. LPA met with Rebecca Whitley , new Administrator. Facility has census of 3, LPA observed 3 clients during the visit. Two clients observed relaxing at the living room and one client is in his bedroom.

During the health and safety check, LPA toured the facility inside and outside, LPA inspected common areas, bathrooms, kitchen and dining. LPA observed smoke detectors and carbon monoxide detector throughout facility. Enough food supplies were observed. Facility is maintained at a comfortable temperature for the residents in care. First aid kit was observed to be complete. Fire Extinguisher last service date was November 2021.

LPA observed the following:
Unlocked knives, detergent soaps and disinfectants which is accessible to clients in care.

LPA observed clients appeared to be well groomed, neat and comfortable.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiency by POC date may result in additional Civil Penalties.


Exit interview conducted. A copy of this report and appeal rights provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2022
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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Document Has Been Signed on 05/06/2022 01:03 PM - It Cannot Be Edited


Created By: Leslie Ibo On 05/06/2022 at 12:10 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: 05/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/06/2022
Section Cited
CCR
80087(g)

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80087 Buildings 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:
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Staff locked up all items during inspection.


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Based on observation, the licensee did not comply with the section cited above. LPA observed knives, cleaning solutions, and disinfectants were accessible to clients which poses an immediate health, safety or personal rights risk to persons in care.
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Administrator agreed to retrain staff with regulation cited and submit proof of in-service training to CCL by the 5/10/2022.

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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: 05/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2022


LIC809 (FAS) - (06/04)
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