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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803726
Report Date: 03/03/2025
Date Signed: 03/03/2025 01:23:11 PM

Document Has Been Signed on 03/03/2025 01:23 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:
03/03/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Sue Webster-AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:35 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 Analysts (LPAs) Alviso and Contreras arrived to conduct a case management inspection, on 3/3/25 at approximately 9:35am, and met with LPT Judy Columbo.and Administrator Susan Webster. This inspection is being conducted to review operations of the facility to ensure compliance with regulations. Facility is on a compliance plan with the Department, effective 3/21/18, for a period of 2 years.

LPAs toured the facility with the Administrator. Hot water was 114.6 degrees Fahrenheit. Fire extinguishers were serviced and charged as required. Food supply was sufficient. Medications were centrally stored and locked up making them inaccessible to residents in care. Cleaners/disinfectants were locked up and inaccessible to residents in care. Facility had the 72 hour shelter in place required supplies. Sufficient supply of paper products, cleaners, linens, and personal protective equipment (PPE). LPAs toured the resident rooms, bathrooms, and common areas.

LPAs reviewed staff files, including training. All staff had criminal record clearance as required.

The following deficiencies were observed during the inspection:

LPAs observed a big lock hanging on the fire exit gate upon arrival; LPAs obtained photos, and discussed fire clearance approval and the observed fire clearance violation with the Administrator. Administrator stated the lock will no longer be used. LPAs obtained photos. This deficiency will be cited, 80020(a) Fire Clearance- All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal, see LIC809D. Civil penalty assessed in the amount of $500, see LIC421IM.

Per file reviews and interviews with Administrator, there was no proof of staff having had required training on the facility's emergency disaster plan. Administrator was not able to provide the staff training to the LPAs, This deficiency will be cited, HSC 1569.695(b) Emergency Disaster Plan- A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster, see LIC809D.

Continued on LIC809C....

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2025
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 4
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: 03/03/2025
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
Per file reviews and interviews with Administrator, there was no proof of staff having had required ongoing training on the facility's infection control plan. Administrator was not able to provide the staff training to the LPAs, This training will be cited, 87470(c)(1)(C)3 Infection Control Requirements- The description of initial and ongoing training shall address the requirements of subsections (a), (b) and (d), see LIC809D.

Per LPAs observations the facility flooring has areas where it is worn out, lifted, torn/ripped and taped down with worn old wood repair tape, it is also lifted up. LPAs obtained photos. This is a trip hazard and a risk to the health and safety of residents in care. This will be cited, 80087(a) Buildings and Grounds-The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors, 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 Licensed Psychiatric Technician, Judy Columbo. Report and Appeal Rights were provided for the Administrator,

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/03/2025 01:23 PM - It Cannot Be Edited


Created By: Dina Alviso On 03/03/2025 at 12:42 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: 03/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/04/2025
Section Cited
CCR
80020(a)

1
2
3
4
5
6
7
80020(a) Fire Clearance- All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee/Administrator to ensure the fire exit gate (s) are not locked at any time. Fire clearance does not approve any locks on the facility;s fire exit gates. Administrator stated the lock will no longer be used. Submit plan of future compliance with this regulation. POC due 3/4/25.
8
9
10
11
12
13
14
LPAs observed a big lock hanging on the fire exit gate upon arrival; LPAs obtained photos, and discussed fire clearance approval and the observed fire clearance violation with the Administrator. LPAs obtained photos. This is a risk to the health & safety of residents in care. Immediate Civil penalty assessed in the amount of $500. see LIC421IM
8
9
10
11
12
13
14
Type B
03/19/2025
Section Cited
HSC1569.695(b)

1
2
3
4
5
6
7
HSC 1569.695(b) Emergency Disaster Plan- A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee to ensure that all staff obtain annual emergency disaster training as required. Submit plan of future compliance with this requirement, and submit proof of all staff having received the training. POC due 3/19/25.
8
9
10
11
12
13
14
Per file reviews and interviews with Administrator, there was no proof of staff having had required training on the facility's emergency disaster plan. Administrator was not able to provide the staff training to the LPAs. This is a risk to the health & safety of residents in care, and a risk to personal rights of the residents.
8
9
10
11
12
13
14
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: 03/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/03/2025 01:23 PM - It Cannot Be Edited


Created By: Dina Alviso On 03/03/2025 at 12:57 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: 03/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/19/2025
Section Cited
CCR
87470(c)(1)(C)(3)

1
2
3
4
5
6
7
87470(c)(1)(C) (3) Infection Control Requirements- The description of initial and ongoing training shall address the requirements of subsections (a), (b) and (d). This requirement was not met as evideced by:
1
2
3
4
5
6
7
Licensee to ensure that all staff obtain annual infection control training as required. Submit plan of future compliance with this requirement, and submit proof of all staff having received the training. POC due 3/19/25.
8
9
10
11
12
13
14
Per file reviews and interviews with Administrator, there was no proof of staff having had required ongoing training on the facility's infection control plan. Administrator was not able to provide the staff training to the LPAs, This is a risk to the health & safety of residents in care.
8
9
10
11
12
13
14
Type B
03/21/2025
Section Cited
CCR80087(a)

1
2
3
4
5
6
7
80087(a) Buildings and Grounds-The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evideced by:
1
2
3
4
5
6
7
Licensee to ensure the facility flooring is in good condition/good repair at all times as required. Submit plan of repairing and/or replcaing the flooring to ensure that the flooring is not a trip hazard/ health and safety hazard to residents in care. Include plan shwong time frames.
8
9
10
11
12
13
14
Per LPAs observations the facility flooring has areas where it is worn out, lifted, torn/ripped and taped down with worn old wood repair tape, it is also lifted up. LPAs obtained photos. This is a trip hazard and a risk to the health and safety of residents in care.
8
9
10
11
12
13
14
The repairs/replacemnt of flooring needs to be completed in a timely manner. POC due 3/21/25.
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: 03/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2025


LIC809 (FAS) - (06/04)
Page: 4 of 4