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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803691
Report Date: 02/23/2023
Date Signed: 02/23/2023 02:06:25 PM

Document Has Been Signed on 02/23/2023 02:06 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:
02/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Acting Admin Kenya Pigg & Psych Tech Tammi LeeTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA), Erik Gonzalez Campos arrived unannounced on 02/23/2023 to conduct Required - 1 Year inspection. LPA met with acting administrator, Kenya Pigg and psych tech, Tammi Lee. 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. LPA conducted walk through of the facility with psych tech. 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 staff are familiar with 911 procedures and protocols. Toxins are secured and inaccessible in locked cabinet inside the laundry room. Medications are centrally stored and secured. The facility has extra hygiene supplies in hallway closet.

LPA followed up with the concerns noted during Department of Developmental Services semi annual visit on 12/15/2023. Bathrooms light bulbs have been replaced and were observed functioning properly. Sharps and knives were locked and inaccessible.

LPA requested the following documents be submitted to Community Care Licensing within 30 days of today's inspection: LIC 308 Designation of Administrative Responsibility, LIC 610 D Emergency Disaster Plan, Register of Clients, LIC 500 Personnel Report

Exit interview conducted with Kenya Pigg and a copy of this report emailed to the facility.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2023
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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