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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803691
Report Date: 03/10/2022
Date Signed: 03/10/2022 10:31:01 AM

Document Has Been Signed on 03/10/2022 10:31 AM - 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:ELWYN CALIFORNIA - ALDERBROOKFACILITY NUMBER:
496803691
ADMINISTRATOR:FERNANDEZ, KIMBERLY (KIM)FACILITY TYPE:
734
ADDRESS:1925 ALDERBROOK LNTELEPHONE:
(408) 355-9619
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 5CENSUS: 5DATE:
03/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrator, Kimberly FernandezTIME COMPLETED:
10:35 AM
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Licensing Program Analyst (LPA), Erik Gonzalez Campos arrived unannounced to conduct Required - 1 Year inspection at 8:45 AM, and met with administrator, Kimberly Fernandez. LPA was initially greeted by staff, administrator arrived shortly. The inspection was focused on the Infection Control procedures and practices of this facility.

Upon entry staff took LPA's temperature. Posted at the entrance above the visitor sign in sheet were a series of screening questions. COVID postings were observed posted at the front door. Mitigation plan has been submitted and reviewed by Community Care Licensing (CCL).

LPA conducted walk through of the facility with administrator. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. Staff have completed Personal Protective Equipment (PPE) and infection control training through Elwyn. Staff have been N95 fit tested by Elwyn. High touch surface areas are disinfected daily. There is a cleaning sheet/log which details when surfaces are disinfected. Due to current facility census clients could isolate in their own rooms if they became ill. LPA confirmed facility has necessary PPE and supplies to support a client in isolation.

Clients' emergency contact information has been updated and administrator confirmed staff confirmed they are familiar with 911 procedures and protocols. Toxins are secured and inaccessible in locked cabinet inside the laundry room. Medications are centrally stored and locked on the medication cart. The facility has hygiene supplies and PPE located in hallway closet.

Facility is not currently conducting surveillance testing. Facility has a 100% vaccination rate for both staff and clients.

Continued on LIC 809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ELWYN CALIFORNIA - ALDERBROOK
FACILITY NUMBER: 496803691
VISIT DATE: 03/10/2022
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Common areas allow for social distancing. A day program visits the facility to engage with the clients in activities and to take the clients on walks/outings. Visitation is allowed indoors.

Fire drills are performed monthly, disaster drills every six months, and generator is tested every 14 days. Last fire drill performed 2/3/2022.

Administrator's Certificate expires 11/28/2023

LPA requested the following updated documents:

Personnel Report
Emergency Disaster Plan
Designation of Facility Responsibility

Exit interview conducted with administrator and a copy of the report printed for the facility.

No deficiencies cited during this inspection
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
LIC809 (FAS) - (06/04)
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