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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803724
Report Date: 01/08/2024
Date Signed: 01/08/2024 09:39:46 AM

Document Has Been Signed on 01/08/2024 09:39 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 - 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:
01/08/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Shift Lead, Rob MatteriTIME COMPLETED:
09:45 AM
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At approximately 8:50AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Other visit and met with Shift Lead, Rob Matteri. The purpose of the visit is to to follow up on findings and recommendations found from the Semi-Annual Review visit conducted by Department of Developmental Services (DDS) on 12/19/2023. Upon arrival, LPA was informed that there were currently 4 clients in care. LPA was informed that 2 clients were out of the community at their Day Programs and the other 2 clients were leaving the facility to go on an outing.

LPA conducted a walk-through of the facility with Shift Lead. LPA observed that chemicals, sharps, and other hazardous materials were locked and inaccessible to clients in care. LPA observed that all client rooms were free of cobwebs and that 1 of 2 bathrooms had paper towel products. Per conversation with Shift Lead, one bathroom does not have a paper towel dispenser due to client behaviors. Clients who utilize the bathroom are provided with paper towels when needed to lessen their behaviors. LPA observed a supply of paper products available on-site when needed.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Shift Lead. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2024
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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