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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803691
Report Date: 04/09/2024
Date Signed: 04/09/2024 03:26:13 PM

Document Has Been Signed on 04/09/2024 03:26 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:ELWYN CALIFORNIA - ALDERBROOKFACILITY NUMBER:
496803691
ADMINISTRATOR/
DIRECTOR:		FERNANDEZ, KIMBERLY (KIM)FACILITY TYPE:
734
ADDRESS:1925 ALDERBROOK LNTELEPHONE:
(707) 791-7531
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 5CENSUS: 4DATE:
04/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:49 AM
MET WITH:CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Caregiver (S1). Administrator Kimberly Fernandez was unavailable as she was attending a corporate function out of town. LPA spoke to Admin via telephone, Admin gave permission for S1 to sign report. Facility currently has four (4) residents in care.

At approximately 9:45am LPA and S1 toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered and labeled with opened dates present. LPA observed all cleaning products and laundry soaps to be stored in locked cabinets in the laundry room and inaccessible to residents in care.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathrooms had required bath mats and grab bars. Water temperature in sinks measured at 112.8 degrees F in the bathroom used by residents, both of which are within the allowable range of 105 to 120 degrees F. Facility has another bathroom used by staff only.

Fire extinguishers were last inspected 07/27/2023. Smoke/Carbon Monoxide detectors located throughout the facility were operational. Facility’s last quarterly disaster drill was conducted on 03/05/2024. Facility has a backup generator for use during a power outage.

Administrator Kimberly Fernandez's Administrator Certificate 6046013735 expired 11/28/2023. Certificate is not showing as either pending or active in CCL database; however, Admin forwarded email confirming her renewal was received by CCL 7/19/2023. All fees are current as of this time.

Continued on 809C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ELWYN CALIFORNIA - ALDERBROOK
FACILITY NUMBER: 496803691
VISIT DATE: 04/09/2024
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At approximately 11:30pm LPA conducted a review of four (4) out of four (4) resident files and 5 staff records. Files complete.

At approximately 12:45pm LPA and S1 reviewed cash resources. No discrepancies.

At approximately 2:00pm LPA and S2 conducted a spot check of medication and medication records. Medication is centrally stored in medication cart. Multiples of medications are stored in locked cabinet.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:
LIC500- Personnel Report
LIC308- Designation of Responsibility
Surety Bond

No deficiencies cited during this inspection. Exit interview conducted with S1 and a copy of this report was given.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024
LIC809 (FAS) - (06/04)
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