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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803691
Report Date: 05/13/2022
Date Signed: 05/13/2022 04:12:51 PM

Document Has Been Signed on 05/13/2022 04:12 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, 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:
05/13/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:55 PM
MET WITH:RN, Madison BarsugliaTIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced to conduct a proof of correction (POC) inspection. LPA met with RN, Madison Barsuglia.

LPA toured facility and observed that the flooring on the side of the house where the client bedrooms are located has been completely replaced.

LPA generated POC letter during inspection.

Exit interview conducted with RN. LPA unable to print report during inspection. Report emailed to administrator.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2022
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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