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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200634
Report Date: 08/31/2021
Date Signed: 08/31/2021 04:02:05 PM

Document Has Been Signed on 08/31/2021 04:02 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:
08/31/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Adrian ViernessTIME COMPLETED:
04:30 PM
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On 8/31/2021 at 3:00 PM Licensing Program Analyst (LPA) L. Ibo arrived unannounced to conduct an annual required inspection. LPA met with nurse Adrian Vierness. Facility Administrator is on leave. Facility has census of 3 . Facility is on yellow zone during the visit per local public health and nurse Adrian V.

LPA toured the facility inside and out including but not limited to common areas, resident rooms, bathrooms, kitchen and patio. No bodies of water. Facility has enough supplies of PPEs, paper supplies and hygiene supplies. Medications are centrally stored in a locked area that is inaccessible to clients and refilled every at least 30 days.

Facility has enough 2-day perishable food and one-week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE . Facility has a mitigation plan and maintains record of routine screening for residents and staff.

No deficiency cited during the visit.

Exit interview conducted. Appeal Rights and copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2021
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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