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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803724
Report Date: 09/16/2021
Date Signed: 09/16/2021 02:58:54 PM

Document Has Been Signed on 09/16/2021 02:58 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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
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: 3DATE:
09/16/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator, Christina TheTIME COMPLETED:
03:10 PM
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Licensing Program Analyst Willis arrived unannounced to conduct a Case Management inspection and met with Administrator, Christina The.

LPA is following up regarding an incident that was self-reported by the facility for a medication error. Facility reported a medication error occurring 7/19/2021 for client, C1 where a medication was not given. Error was found during an audit. Client did not have any adverse effects from missing medication.

A Civil Penalty in the amount of $250.00 is being assessed due to a repeat violation of the same regulation in a 12 month period.

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: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2021
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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Document Has Been Signed on 09/16/2021 02:58 PM - It Cannot Be Edited


Created By: Victoria Willis On 09/16/2021 at 02:29 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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: ELWYN CALIFORNIA - HAPPY VALLEY
FACILITY NUMBER: 496803724

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/17/2021
Section Cited
CCR
80075(b)

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80075 Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. Requirement was not met as evidenced by: Based on document and interview, C1 was not given their medication on 7/19/2021. This is an immediate health and safety risk to clients in care.
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Administrator has increased medication audits and provided additional training to staff through the facility's quality assurance unit. Involved staff no longer works at this facility and facility has not had any additional medication errors. Deficiency is cleared.

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A Civil Penalty in the amount of $250.00 is being assessed due to a repeat violation of the same regulation in a 12 month period.

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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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Victoria Willis
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2021


LIC809 (FAS) - (06/04)
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