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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803726
Report Date: 08/01/2024
Date Signed: 08/01/2024 01:54:20 PM

Document Has Been Signed on 08/01/2024 01:54 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:ELWYN CALIFORNIA - BARNESFACILITY NUMBER:
496803726
ADMINISTRATOR/
DIRECTOR:		WEBSTER, SUSANFACILITY TYPE:
737
ADDRESS:4151 BARNES RDTELEPHONE:
(707) 791-3937
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 4CENSUS: 4DATE:
08/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Lucy Campbell-Licensed Psychiatric TechnicianTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
NARRATIVE
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Licensing Program Analysts (LPAs), Alviso and Loera, arrived to conduct a Required -1 Year inspection, on 8/1/24 at approximately 8:40am, and met with Lead LPT Lucy Campbell. LPT contacted the Administrator to notify them of the LPAs arrival. The Administrator Susan Webster arrived to the facility to meet with the LPAs.

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. Fire/emergency drills are being conducted as required; Last drills. fire and earthquake drills were held on 7/6/24.

LPAs reviewed four (4) client files. All files were complete. Two (2) clients are on restricted health care plans, and staff are trained in meeting both clients needs, including medications.

LPAs reviewed five (5) staff files. All files were complete.

All exits were clear, and unobstructed. Hot water was checked at 107.5 degrees Fahrenheit, which is within regulation. All fire extinguishers, two(2), were serviced and tagged as required. 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.

Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 - BARNES
FACILITY NUMBER: 496803726
VISIT DATE: 08/01/2024
NARRATIVE
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LPA is requesting the following forms be updated and submitted by 08/30/24
LIC 500 -Personnel Report
LIC 610D - Emergency Disaster Plan, Review & Update- Submit updated plan to CCL
Infection Control Plan-review-update if needed-
LIC 308 - Designation of Responsibility
Affidavit Regarding Client Cash Resources
Copy of Surety Bond
Copy of Administrator certificate

Administrator could not provide the infection control plan to the LPAs for review. This is a required plan, and is a part of the facility's operation. This deficiency will be cited. Infection Control Requirements-85095.5(c)- An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022.

LPA reviewed a resident incident report, and had obtained additional information from the Administrator. In review of the incident, staff S2 was providing care and supervision to client C3 who was exhibiting behaviors and hit S2. S2 yelled out the following: "I'm not doing this anymore. I can't work with C3. I'm out of here." C3 has a care plan, including how staff are to address client's behaviors/meet client's needs. Staff providing care and supervision to clients are trained in meeting the clients needs at all times. Deficiency will be cited: Personal Rights 80072(a)(1) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: To be accorded dignity in his/her personal relationships with staff and other persons, 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: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/01/2024 01:54 PM - It Cannot Be Edited


Created By: Dina Alviso On 08/01/2024 at 12:01 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: 08/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80072(a)(1)
Personal Rights 80072(a)(1) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: To be accorded dignity in his/her personal relationships with staff and other persons.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Review of the incident, staff S2 was providing care and supervision to client C3 who was exhibiting behaviors and hit S2. S2 yelled out the following: "I'm not doing this anymore. I can't work with C3. I'm out of here." C3 has a care plan, including how staff are to address client's behaviors/meet client's needs. Staff providing care and supervision to clients are trained in meeting the clients needs at all times, including during behaviors. This iincident s a risk to resident's personal rights.
POC Due Date: 08/16/2024
Plan of Correction
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 Administrator will hold an in-service with all staff regarding resident's personal rights, ensuring that residents rights are not violated at any time. Submit proof of training. POC due 8/16/24.
Type B
Section Cited
CCR
85095.5(c)
Infection Control Requirements-85095.5(c)- An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs record reviews there was no infecion control plan, and the Administrator couldn't provide the plan to the LPAs for review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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Licensee/Administrator to develop an infection control plan as required, ensuring the plan is incompliance with regulations. Ensure all staff are trained regarding the facility's "infection control plan" . Submit a copy of the infection control plan, and proof of in-service with all staff, to CCL. POC due 8/30/24.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2024


LIC809 (FAS) - (06/04)
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