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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803726
Report Date: 06/29/2023
Date Signed: 06/29/2023 10:58:33 AM

Document Has Been Signed on 06/29/2023 10:58 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:ELWYN CALIFORNIA - BARNESFACILITY NUMBER:
496803726
ADMINISTRATOR:WEBSTER, SUSANFACILITY TYPE:
737
ADDRESS:4151 BARNES RDTELEPHONE:
(707) 791-3937
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 4CENSUS: 4DATE:
06/29/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator-Susan WebsterTIME COMPLETED:
11:00 AM
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A Non-Compliance meeting was conducted today, 6/29, in the Santa Rosa Regional Office. Present in the meeting were Regional Manager Carla Martinez, Licensing Program Manager Bethany Moellers, Licensing Program Analyst Dina Alviso, facility Administrator Susan Webster, and Regional Director Reggie San Pablo.

This Compliance Plan Conference is being conducted to discuss concerns identified by the Licensing Agency regarding the operation of this facility, regarding Complaint #21-AS-20230322142833, received on 3/22. The investigation substantiated that the facility is not operating in a sanitary manner and/or in good repair; Clients are not able to use restroom toilets in a sanitary manner, and Facility is not submitting required reports/incidents. The following are concerns that have been identified during the complaint investigation:

Building & Grounds: Facility’s toilets (2) were not working appropriately/not able to be used, and clients were made to use the toilet(s) in an unsanitary manner.

Personal Rights: The facility staff started using plastic bags in the toilet(s) for clients to urinate and/or have bowel movements in, this was instituted by staff when the toilets couldn’t be used.

Reporting Requirements: Facility did not ensure that CCL was notified about incident(s), that began on 3/13, after facility restrooms both had flooding, separate incident dates, due to a septic tank issue; The septic tank issue resulted in the facility toilets (2) not being able to be used. The facility never contacted licensing to report the incident, and the facility didn’t submit the required written report until 3/22/23.

Continued on LIC809C...
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2023
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
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: 06/29/2023
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CCL has provided copies of the following Regulations and Health & Safety Code: #80087 Building & Grounds, # 80072 Personal Rights, #80061 Reporting Requirements, and Health & Safety Code 1565 Emergency & Disaster Plan.
Licensee agreed to do the following, to bring the facility into compliance no later than the following dates:

Building & Grounds 80087: Facility will ensure buildings and grounds are maintained, in good repair at all times, ensuring facility is operational, and clients services are provided to them in a healthy and safe manner as required. Submit, by 7/7/2023, update on the septic tank, current status, and plan of action until the septic tank issue(s) are resolved.
Emergency and Disaster Plan: H&S 1565: Ensuring that facility enacts the emergency disaster plan as needed, ensuring clients are provided services in a healthy and safe manner. Licensee/Regional Director to hold an in-service training with all staff on the facility’s “Emergency Disaster Plan.” Submit, by 7/18/2023, proof of training, including all attendees, and date/time spent.
All future staff will be provided the Emergency Disaster training as they are hired, please also submit written self-certification of ensuring this requirement is met.
Personal Rights 80072 : Each client shall have personal rights, including to be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment to meet his/her needs. Facility will contact an outside vendor to conduct training for all staff on “Clients Personal Rights.” Submit, by 7/18/2023, proof of training, including all attendees, and date/time spent.

Reporting Requirements 80061: Facility will ensure all incidents that threaten the health & safety of clients are reported to CCL per regulation. Facility will contact an outside vendor to conduct training for all staff on “Reporting Requirements.” Submit, by 7/18/2023, proof of training, including all attendees, and date/time spent.

Continued on LIC809C...
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023
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: 06/29/2023
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Water Supply 80021: Subsequent to initial licensure, the licensee shall provide evidence of a bacteriological analysis of the private water supply as frequently as is necessary to ensure the safety of the clients, but no less frequently than specified in the following table: 6 or fewer, Initial Licensing Not required unless evidence supports the need for such analysis to protect clients. Regarding incident of septic tank issues, have a water analysis done regarding the safety of the water for clients in care. Submit by 7/18/2023.

Facility was placed on a compliance plan for 2 years. Licensee has been advised that failure to comply with the terms and conditions of the two-year compliance plan may result in administrative action.

Facility is subject to increased quarterly monitoring to ensure compliance.

There were no deficiencies cited at this time.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023
LIC809 (FAS) - (06/04)
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