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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803724
Report Date: 07/09/2024
Date Signed: 07/09/2024 02:30:13 PM

Document Has Been Signed on 07/09/2024 02:30 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 - HAPPY VALLEYFACILITY NUMBER:
496803724
ADMINISTRATOR/
DIRECTOR:
THE, CHRISTINAFACILITY TYPE:
737
ADDRESS:3500 HAPPY VALLEY CTTELEPHONE:
(707) 536-9351
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 4CENSUS: 4DATE:
07/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:50 AM
MET WITH:Christina The (Administrator)TIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Cuadra, arrived unannounced to conduct an Annual Required Inspection and met with Administrator, Christina The. Clients were attending day program during visit.

LPA/Administrator tour the facility 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 bathrooms measured at 109.2 and 111.7 degrees F which are within allowable range of 105 to 120 degrees F. Extra hygiene products and linens were available. Kitchen cabinet containing cleaning supplies was locked as well as the kitchen drawer containing knives. Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored and locked in a cabinet. Cash resources and their documentation were reviewed. Fees are current.

Fire extinguishers were last inspected May, 2024. Facility has hardwired combination Smoke/Carbon Monoxide detectors located throughout the facility that were operational. Facility is equipped with a fire door that closes when smoke alarms are activated. Most recent Fire/Disaster Drill was conducted 5/13/2024. Hospice waiver for 1 resident was reviewed.

File review was initiated at 12:30 pm. Three staff files and four client files were reviewed. Staff have required First Aid and CPR certificates. Administrator Certificate for Administrator, Christina The 7054251735 expires 9/22/2025. Medications and medication records were reviewed.

Administrator to submit updates of the following documents by 7/19/2024: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), surety bond and lease agreement.

No deficiencies cited during this inspection. Exit interview was conducted with Administrator and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2024
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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