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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803691
Report Date: 07/14/2022
Date Signed: 07/14/2022 03:37:07 PM

Document Has Been Signed on 07/14/2022 03:37 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:
07/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:RN, Rene LitzenbergTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced to conduct a case management inspection regarding an incident received by Community Care Licensing on 06/10/2022. LPA met with House Manager (RN), Rene Litzenberg.

Incident report received by licensing on 06/10/2022 indicated that a PRN medication was not given following a client's seizure. Error was found following a review of the MAR by North Bay Regional Center Nurse. Following the incident, the facility conducted in-service training. LPA was provided with a manifest of the training. No signs of symptoms or distress were noted with the client.

Exit interview conducted with Rene Litzenberg. A copy the report was printed for the facility.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2022
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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