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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200634
Report Date: 03/01/2023
Date Signed: 03/01/2023 12:07:52 PM

Document Has Been Signed on 03/01/2023 12:07 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:WHITLEY, REBECCA LFACILITY TYPE:
737
ADDRESS:2934 TERRA VERDE LNTELEPHONE:
(925) 418-4168
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 4CENSUS: 3DATE:
03/01/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Rebecca Whitley, Administrator TIME COMPLETED:
12:30 PM
NARRATIVE
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On 03/1/2023, while conducting another inspection visit, Licensing Program Analyst (LPA) Leslie Ibo
conducted unannounced Case Management inspection.

While conducting staff interview, it was revealed that facility is under covid19 quarantine from local public health and was not cleared yet. LPA found out there were three (3) staff who tested covid19 positive for the month of Feb 2023. This was not reported to CCL therefore a deficiency was cited.

The following deficiencies was observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties.


Exit interview conducted. Appeal Rights and a copy of this report was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2023
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 03/01/2023 12:07 PM - It Cannot Be Edited


Created By: Leslie Ibo On 03/01/2023 at 11:51 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 - TERRA VERDE
FACILITY NUMBER: 079200634

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/06/2023
Section Cited
CCR
80061(b)(1)(E)

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Reporting Requirements: Upon the occurrence… of any of the events specified…a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report …. shall be submitted to the licensing agency within seven days.......
-This requirement is not met as evidenced by:
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Administrator stated that she will submit the incident reports pertaining to three staff that tested positive for the month of February 2023. In addition, administrator will send self-certification that she read the Regulation and ensure reports are submitted within Regulation’s time frame.
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-Based on interview, licensee did not comply with the above Regulation by failing to submit incident reports to CCL which poses potential health, safety and personal right risks to persons in care.
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Proof to be submitted by 3/6/2023.

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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: 03/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2023


LIC809 (FAS) - (06/04)
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