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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803724
Report Date: 08/13/2024
Date Signed: 08/13/2024 10:41:00 AM

Document Has Been Signed on 08/13/2024 10:41 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
SANTA ROSA RO, 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:
08/13/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:57 AM
MET WITH:CaregiverTIME VISIT/
INSPECTION COMPLETED:
10:55 AM
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At approximately 9:00am, Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Case Management and met with caregiver. Administrator Christina The was not available, but contacted via telephone. Administrator gave caregiver permission to sign report.

On 7/3/2024 CCL received an incident report for medication error that occurred on 6/29/24 and 6/30/2024. The Incident report states that resident (R1) returned to facility from hospital with Glipizide XL 20mg medication that was not entered into the MAR and therefore not administered on 6/29/24 and 6/30/2024. NOC shift lead noticed the error and notified the AM lead. AM lead corrected the MAR immediately upon being notified of the error. Facility immediately notified R1's doctor of medication error. Facility monitored R1 for adverse effects; no adverse effects or changes observed due to medication error. Per Administrator, the facility conducts training on medication management on an on-going basis, but has not conducted training after this incident occurred. Facility will conduct training on medication management as part of plan of correction.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with caregiver. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with caregiver and a copy of this report was given.

**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)**

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2024
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 08/13/2024 10:41 AM - It Cannot Be Edited


Created By: Christi Coppo On 08/13/2024 at 10:17 AM
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: 08/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/14/2024
Section Cited
CCR
80075(b)

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80075 Health Related Services (b) Clients shall be assisted...with self-administration of prescription and nonprescription medications.

This requirement was not met by licensee as evidenced by:
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Facility to submit to CCL plan to conduct staff training on medication management by plan of correction due date. Training to be completed no later than 8/27/2024. Training log to be submitted and include name of trainer, duration of course, course name, and all staff attendees.
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Based on Incident Report, 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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024


LIC809 (FAS) - (06/04)
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