<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803691
Report Date: 02/10/2022
Date Signed: 02/10/2022 12:36:27 PM

Document Has Been Signed on 02/10/2022 12:36 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:
02/10/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator, Kimberly FernandezTIME COMPLETED:
12:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced at approximately 10:30 AM to conduct a case management inspection. LPA was greeted by administrator and asked to sign in after symptom screening.

LPA toured facility with administrator and observed damaged floorboards near nursing station, in hallway accessible to clients and in client bedroom. Floorboards in hallway are separated and can be lifted. Floorboards in client bedroom appear bowed. Photos taken.

LPA also reviewed staffing schedule. Registered nurse was awake and available for at least 40 hours per week in 3 of 4 weeks during the month of January.

Exit interview conducted with administrator and a copy of this report printed for the facility.


Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 02/10/2022 12:36 PM - It Cannot Be Edited


Created By: Erik Gonzalez Campos On 02/10/2022 at 12:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ELWYN CALIFORNIA - ALDERBROOK
FACILITY NUMBER: 496803691

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/28/2022
Section Cited
CCR
80087(a)

1
2
3
4
5
6
7
80087(a) Buildings and Grounds. The facility shall be kept clean, sanitary and in good repair at all times.
1
2
3
4
5
6
7
Licensee agrees to submit photo verification that the flooring has been repaired or replaced and submit self certification along with a photo to CCL by POC 2/28/2022.
8
9
10
11
12
13
14
This requirement is not met as evidenced by:
Based on LPAs observation and interview the facility failed to ensure flooring in 1 client bedroom and hallway was in good repair which poses a potential health and safety risk to clients in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kimberley Mota
LICENSING EVALUATOR NAME:Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2