<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803726
Report Date: 08/04/2022
Date Signed: 08/04/2022 01:15:54 PM

Document Has Been Signed on 08/04/2022 01:15 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 - BARNESFACILITY NUMBER:
496803726
ADMINISTRATOR:ABBOTT-FLOREZ, ROBERTFACILITY TYPE:
737
ADDRESS:4151 BARNES RDTELEPHONE:
(707) 791-3937
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 4CENSUS: 4DATE:
08/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Judy Colombo- LPTTIME COMPLETED:
01:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Alviso arrived to conduct a required 1 Year inspection and met with Lead LPT staff Judy Colombo. This inspection is focused on the infection control procedures and practices of this facility.

Fire door was under repair upon LPA's arrival; Hue & Cry repair services for the fire alarm system was on-site and spoke with the LPA; Facility's fire door is now working properly after repairs-effective today, 8/4/2022.

LPA reviewed two resident incident reports submitted to the Department; LPA obtained additional information regarding both incidents. It was found that a medication was not given to a client as prescribed, this deficiency will be cited, 80075(b)(5)(B) Health Related Services-see LIC809D.

Facility has recently submitted the new Infection Control Plan as required by the Department. Fire clearance is approved for four (4) non-ambulatory, of which four(4) may be bedridden.

There are four 4 clients in care at the facility. All visitors and staff are screened upon entry; Temperatures are taken, screening questions are to be answered before being allowed to enter and remain in the facility, all information is logged. Clients are screened daily and as often as needed, clients are observed for any changes, and all information is logged.

Facility was found to be clean, orderly, and at a comfortable temperature with exits free from obstruction. Toxins are stored in locked cabinets.

Continued on LIC809C....
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 08/04/2022 01:15 PM - It Cannot Be Edited


Created By: Dina Alviso On 08/04/2022 at 12:22 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 - BARNES
FACILITY NUMBER: 496803726

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(B)
80075 (b)(5)(B) Health Related Services (b)Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, providing all of the following requirements are met (B)Once ordered by the physician the medication is given according to the physician's directions. Per staff Judy, the staff (S1) who was involved in the medication error was retrained in medication assistance. The documents of plan of correction and proof of training will be submitted as requested.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
LPA's review of incident and interview with facility staff, Per staff Judy, staff (S1) who was involved in the medication error was retrained in medication assistance. Based on interview, and record review, the licensee did not comply with the section cited above in [1] out of [4] client medications being provided, which poses an immediate health, safety and/or personal rights risk to persons in care.
POC Due Date: 08/05/2022
Plan of Correction
1
2
3
4
Licensee to ensure that all clients receive their medications as prescribed by the Physician; Licensee to ensure the staff that handle medications are trained as required and as needed, in facility’s policies and procedure of “medication assistance to clients in care”. Please submit plan on ensuring staff provide medications to clients in care as required and proof of training provided to staff (S1). POC due 8/5/2022.

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:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 - BARNES
FACILITY NUMBER: 496803726
VISIT DATE: 08/04/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Medications are stored locked making them inaccessible to clients in care. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment(PPE). All staff were observed to have masks on as required.

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, and/or the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Appeal Rights Given.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3