<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609743
Report Date: 08/23/2021
Date Signed: 08/23/2021 01:49:00 PM

Document Has Been Signed on 08/23/2021 01:49 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ELWYN CALIFORNIA - QUARTZFACILITY NUMBER:
197609743
ADMINISTRATOR:JOSEPH TIGHEFACILITY TYPE:
737
ADDRESS:8033 QUARTZ AVETELEPHONE:
(925) 626-7014
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY: 2CENSUS: 2DATE:
08/23/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Steveh WamalaTIME COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Wendell Smith conducted a unannounced case management visit. LPA met with facility staff and explained the reason for this visit. Purpose of this visit is in reference to complaint 31-AS-20210520170248. During the investigation it was unsubstantiated regarding staff # 1 (S1) hitting client #1 (C1). However interviews did reveal that S1 did not treat C1 with dignity and respect by attempting to intimidate C1 by banging on the table when attempting to get C1 to do something. Based on this information there is a citation issued regarding this issue. Facility has already corrected the deficiency.
Exit Interview conducted
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 08/23/2021 01:49 PM - It Cannot Be Edited


Created By: Wendell Smith On 08/23/2021 at 11:21 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELWYN CALIFORNIA - QUARTZ
FACILITY NUMBER: 197609743

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/23/2021
Section Cited
CCR
80072(a)(1)

1
2
3
4
5
6
7
Personal Rights-To be accorded dignity in his/her personal relationships with staff and other persons.
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Corrected before visit. S1 employment was terminated by the facility.
8
9
10
11
12
13
14
Based on interviews conducted it was revealed that S1 was rude to C1 and would bang on the table to try to intimidate C1. This posed a potential health and safety risk to clients in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Cassandra Harris
LICENSING EVALUATOR NAME:Wendell Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2021


LIC809 (FAS) - (06/04)
Page: 2 of 2