496803726-8-3-2023-21-AS-DALO-CUD26M-20230803170722

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803726
Report Date: 08/03/2023
Date Signed: 08/03/2023 05:07:27 PM

Document Has Been Signed on 08/03/2023 05:07 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 - BARNES		FACILITY NUMBER:	496803726
ADMINISTRATOR:	WEBSTER, SUSAN		FACILITY TYPE:	737
ADDRESS:	4151 BARNES RD		TELEPHONE:	(707) 791-3937
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY: 4		CENSUS: 4	DATE:	08/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Susan Webster-Administrator		TIME COMPLETED:	05:15 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, on 8/3/23 at approximately 9:30am, and met with Lead LPT Lucy Campbell. The Administrator Susan Webster arrived to the facility, and met with the LPA. Facility has a required infection control plan. Facility has a required emergency disaster plan. Facility is fire cleared for four(4) non-ambulatory, of which four(4) may be bedridden. There are four(4) clients in care. One(1) of the four(4) clients attends day program. The LPA toured the facility with the Administrator. All exits were clear, and unobstructed. Hot water was checked at 112.1 F., which is within regulation. All fire extinguishers, two(2), were serviced and tagged as required- expires 7/27/24. All smoke alarms, nine(9), which are also carbon monoxide detectors, were checked and working properly during the inspection. Perishable and non-perishable food was sufficient. Sufficient supply of hygiene products, paper products, and disinfectant cleaners. All medications were locked up, and inaccessible to clients in care. All disinfectants, and tools were locked up and inaccessible to clients in care. Facility was at a comfortable temperature. The facility was observed by the LPA to be clean and orderly. The facility had a sufficient supply of personal protective equipment(PPE). The facility had sufficient lighting throughout the home. LPA reviewed the facility's compliance plan during today's inspection; Per review, facility is meeting requirements of the plan. The facility water(septic tank) was tested and found to have no bacteria, per report by Alpha Analytical Laboratories. Continued on LIC809C....

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

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: 08/03/2023

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

Permits are being obtained so the septic tank repairs/replacement can be started soon. Facility has also conducted emergency plan training with all staff, and submitted the proof of training. Personal rights training was completed, proof of training submitted. Reporting requirements has been scheduled, Administrator will submit the proof of training as discussed during the inspection. Administrator will continue to ensure compliance with the compliance plan as required.

LPA is requesting the following forms be updated and submitted to CCL by 09/3/2023:
· LIC 500 -Personnel Report
· LIC 610D - Disaster Plan, Review & Update if Needed- Submit updated plan if any changes and/or submit reviewed/signed and dated last page if there were no changes required.
· Infection Control Plan-submit if any changes and/or required updates
· LIC 308 - Designation of Responsibility
· Affidavit Regarding Client Cash Resources
· Copy of Surety Bond

LPA reviewed four(4) client records. All records were complete. LPA reviewed five(5) staff records, including training. All staff have required criminal record clearances. Two(2) out of five(5) staff lacked required current First Aid certification, and one(1) of the two(2) lacked current CPR certification. This deficiency will be cited, 89965(k)(1) - Direct care staff shall maintain current certifications in first aid and cardiopulmonary resuscitation, see LIC809D.

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.

Exit interview conducted with the Administrator. Appeal Rights provided to Susan Webster, Administrator.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 08/03/2023 05:07 PM - It Cannot Be Edited

Created By: Dina Alviso On 08/03/2023 at 04:26 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: 08/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

89965(k)(1)

Personnel Requirements

(1) Direct care staff shall maintain current certifications in first aid and cardiopulmonary resuscitation. The administrator shall maintain the certifications in the facility personnel records. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's (record review), two(2) out of five(5) staff lacked required current First Aid Certification, and one(1) of the two(2) staff lacked current CPR certification, the licensee did not comply with the section cited above in [2] out of [5] staff, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/11/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator to esure staff obtain First Aid and CPR certification as required. Submit copies of recertification to licensing office by POC due date of 8/11/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Carla Martinez

LICENSING EVALUATOR NAME:

Dina Alviso

LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3