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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803726
Report Date: 03/21/2024
Date Signed: 03/21/2024 03:45:53 PM

Document Has Been Signed on 03/21/2024 03:45 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:WEBSTER, SUSANFACILITY TYPE:
737
ADDRESS:4151 BARNES RDTELEPHONE:
(707) 791-3937
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 4CENSUS: 4DATE:
03/21/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Susan Webster-AdministratorTIME COMPLETED:
03:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alviso arrived to conduct a case management inspection, on 3/21/24 at approximately 9:25am, and met with LPTs Lucy Campbell, and Judy Columbo. Administrator Susan Webster was contacted to notify them of LPAs arrival to the facility. This inspection is to follow-up on the Semi Annual Report recently conducted by CDDS. LPA reviewed the report findings with the Administrator, and requested additional information on specific items. The LPA also toured the facility.

It was identified by a professional contractor during the LPA's inspection that the surge protector, plugged into the outlet, was bad and no longer working. The surge protector was removed, and the LPA observed that the outlet was working properly. LPA observed that the second bathroom had a new shower head installed, and can be used if needed. There is a main bathroom with a large roll in shower for clients use, and this is the bathroom used for client bathing.

LPA conducted file reviews, observed staff had current training certificates in the file of required training. Per file reviews, there was a medication that was not being used for C1 upon discharge, 12/13/23, but was shown on the medication list; Per review this medication was a PRN, and was not included with discharged medications for C1. C1 had 12/19/23 follow-up Dr. appointment and this medication was not on the provided medication list.

The MAR record showed the medication on January and February records even though C1 was not prescribed the medication when discharged. Administrator followed-up and requested discontinue order due to the medication still showing up on MAR records.

Per file reviews, facility has centrally stored medication records and MAR records for documenting client medications, the records had required medication information.

Continued on LIC809C....
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2024
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 03/21/2024 03:45 PM - It Cannot Be Edited


Created By: Dina Alviso On 03/21/2024 at 03:16 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: 03/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/05/2024
Section Cited
CCR
80092.1(f)(2)

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General Requirements for Restricted Health Conditions 80092.1 (f) (2) Prior to admission of a client with a restricted health condition specified in Section 80092, the licensee shall: Ensure that facility staff who will participate in meeting the client's specialized care needs complete training provided by a licensed professional sufficient to meet those needs.
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Licensee/Administrator to ensure all staff providing RHCP services to C3 are trained by a licensed professional, such as an RN, as required by regulation. Submit plan of future complaince with this regulation, and proof of staff training on C3's RHCP.
POC due 4/5/24.
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This requirement has not been met as evidenced by Per LPA's file review, C3 has a restrictive health care plan (RHCP) completed by an RN, but there is no proof of staff training on the RHCP as required. This is a risk to personal rights and/or to health and safety of the resident.

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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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024


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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ELWYN CALIFORNIA - BARNES
FACILITY NUMBER: 496803726
VISIT DATE: 03/21/2024
NARRATIVE
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LPA reviewed regulations with the Administrator on medications, medication records, restricted conditions, restricted health care plans, staff training, training records, and buildings and grounds.

Per LPA review of records, C3 has a restrictive health care plan (RHCP) completed by an RN, but there is no proof of staff training on the RHCP as required. This deficiency will be cited, General Requirements for Restricted Health Conditions 80092.1(f) (2) Ensure that facility staff who will participate in meeting the client's specialized care needs complete training provided by a licensed professional sufficient to meet those needs, 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 the Administrator,

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

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
LIC809 (FAS) - (06/04)
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