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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803724
Report Date: 06/22/2023
Date Signed: 06/22/2023 12:58:18 PM

Document Has Been Signed on 06/22/2023 12:58 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 - HAPPY VALLEYFACILITY NUMBER:
496803724
ADMINISTRATOR:THE, CHRISTINAFACILITY TYPE:
737
ADDRESS:3500 HAPPY VALLEY CTTELEPHONE:
(707) 536-9351
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 4CENSUS: 4DATE:
06/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Christina TheTIME COMPLETED:
01:08 PM
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Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and met with Administrator, Christina The.

LPA initiated a tour of the facility around 9:15am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Client rooms were furnished per regulation. Water temperature in client bathroom measured at 110 degrees F which is within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Kitchen cabinet containing cleaning supplies was locked. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked in the office. Emergency food and water supplies are stored in the garage along with Personal Protective Equipment.

Fire extinguisher was last serviced August 2022. Facility has combination Smoke/Carbon Monoxide detectors located throughout the facility that were recently tested by the local fire department. Noted issues were remedied by the facility. Most recent fire/disaster drill was conducted June 20, 2023.

Four staff files and four client files were reviewed. Administrator Certificate for Administrator Christina The 6045867735 expires 9/21/2023. Staff training was reviewed. Medications and medication records and client cash resources were also reviewed.

Continued on LIC809C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2023
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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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 - HAPPY VALLEY
FACILITY NUMBER: 496803724
VISIT DATE: 06/22/2023
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Continued from LIC809

Administrator provided LPA an updated LIC400 Affidavit Regarding Client Cash Resources to reflect changes to amount of cash resources.

Licensee/Administrator to submit updates of the following documents by 7/22/2023:


LIC308 Designation of Responsibility
LIC 610 Emergency Disaster Plan (If changes)
Infection Control Plan (If changes)

No deficiencies cited during this inspection
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
LIC809 (FAS) - (06/04)
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