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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803724
Report Date: 02/23/2024
Date Signed: 02/23/2024 03:52:18 PM

Document Has Been Signed on 02/23/2024 03:52 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:THE, CHRISTINAFACILITY TYPE:
737
ADDRESS:3500 HAPPY VALLEY CTTELEPHONE:
(707) 536-9351
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 4CENSUS: 4DATE:
02/23/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Administrator, Christina TheTIME COMPLETED:
04:00 PM
NARRATIVE
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At approximately 3:00PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident visit and met with Administrator, Christina The. The purpose of the visit is to to follow up on an incident report that was submitted to Community Care Licensing (CCL).

Incident Report 1: CCL received an incident report on 01/03/2024. Report states that on 12/31/2023, facility staff observed dispensed medication in the staff office for Resident 1 (R1). The dispensed medication was to be given at noon. Facility monitored R1 for adverse effects. Facility conducted in-service training on medication administration. Facility made all appropriate notifications per regulation.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

LPA was provided with a copy of training documentation for medication administration. LPA cleared deficiency cited today during visit.

**An Immediate Civil Penalty in the total amount of $250 is being assessed for repeat violations of Regulation 80075(b) for occurring more than once in a 12 month period. (See LIC421FC)**

Exit interview conducted. Plan of Corrections reviewed and developed with Administrator. Copy of report, LIC809D, LIC421FC, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2024
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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Document Has Been Signed on 02/23/2024 03:52 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 02/23/2024 at 03:14 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 - HAPPY VALLEY
FACILITY NUMBER: 496803724

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/24/2024
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.
This requirement is not met as evidenced by: Based on document review, the Licensee did not comply with the section cited above.
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Licensee conducted In-Service Training on Medication Administration 02/12/2024. Deficiency cleared during visit.
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R1 was not given their medication as prescribed. This poses an immediate health, safety or personal rights risk to residents in care.
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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:Kimberley Mota
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2024


LIC809 (FAS) - (06/04)
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