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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200634
Report Date: 07/30/2024
Date Signed: 07/30/2024 02:20:40 PM

Document Has Been Signed on 07/30/2024 02:20 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ELWYN CALIFORNIA - TERRA VERDEFACILITY NUMBER:
079200634
ADMINISTRATOR/
DIRECTOR:		WHITLEY, REBECCA LFACILITY TYPE:
737
ADDRESS:2934 TERRA VERDE LNTELEPHONE:
(925) 418-4168
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 4CENSUS: 4DATE:
07/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:37 AM
MET WITH:Rebecca Whitley, Director/Administrator TIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 07/30/2024 at 10:37 AM, Licensing Program Analyst (LPA)Tonica Syess-Gibson conducted an unannounced annual required inspection. LPA met with Rebecca Whitley, Director/Administrator and explained the purpose of the visit. LPA reviewed CDSS Website Administrator Certificate is in pending status. LPA toured the facility with Rachel Murvine, Caregiver. The facility’s fire clearance was approved for Four (4) Non-Ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of four (4) total bedrooms, two and a half (2 1/2) bathrooms, half (1/2) bathroom used for staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 73 degrees Fahrenheit.

LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 110.1 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ELWYN CALIFORNIA - TERRA VERDE
FACILITY NUMBER: 079200634
VISIT DATE: 07/30/2024
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Continued from LIC809.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 07/01/2024. Emergency Disaster Plan was last posted on 05/15/2022. First aid kit was observed to be complete. Fire drill was last conducted on 07/02/2024.

Five (5) staff records reviewed and complete. All Four (4) clients records reviewed, current, and complete. LPA also reviewed P & I and medications.

The following forms to be updated and submitted to CCLD by 08/06/2024:

· LIC 308 Designation of facility responsibility
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 402 Surety Bond
· LIC 500 Personnel Report
· LIC 610D Emergency Disaster Plan (Updated)


Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC809 (FAS) - (06/04)
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