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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803691
Report Date: 06/15/2023
Date Signed: 06/15/2023 09:48:22 AM

Document Has Been Signed on 06/15/2023 09:48 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: 4DATE:
06/15/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Psychiatric Technician, Tammy Lee
Psychiatric Technician/Back-up Administrator Kenya Pigg		TIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Elwyn California-Alderbrook for the purpose of conducting a Case Management-Other inspection. LPA was greeted at the door by Tammy Lee, and was granted access into the facility. Psychiatric Technician/Back-up Administrator Kenya Pigg arrived 45 minutes later.

During this Case Management-Other inspection, LPA provided a copy of Title 22 regulation: 85064-Administrator Qualifications and Duties. LPA discussed the findings of the Department of Developmental Services (DDS) Report issued on June 9, 2023 and advised of the importance of a back-up Administrator being onsite and accessible to clients in care as well as other Governmental Agencies that visit the facility (See LIC 9102-Technical Violation). During an interview with the back-up Administrator, LPA learned that the Back-up Administrator is here 20 of hours a week. In addition, LPA discussed Reporting Requirements in detail as outlined in Title 22 regulation: 80061-Reporting Requirements. LPA discussed the findings of the Department of Developmental Services (DDS) Report issued on June 9, 2023 and advised of the importance of Reporting Requirements as it pertains to reporting incidents to ALL appropriate parties (See LIC 9102-Technical Violation) as outlined in regulation. LPA provided a copy of the regulations.

LPA requested the following document:

-LIC 500
-Staff Schedule
-Administrators Certificate for Psychiatric Technician/Back-up Administrator
-Vendorization Certificate for Psychiatric Technician/Back-up Administrator

No deficiencies were cited during this Case Management-Other inspection. Exit interview was conducted and a copy of this report was signed and given to the back-up Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2023
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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