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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202112
Report Date: 11/18/2021
Date Signed: 11/18/2021 03:49:28 PM

Document Has Been Signed on 11/18/2021 03:49 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:ELWYN NC - WELLINGTON PARKFACILITY NUMBER:
435202112
ADMINISTRATOR:REYES, JUDYFACILITY TYPE:
735
ADDRESS:4865 WELLINGTON PARK DRTELEPHONE:
(408) 281-1116
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 4CENSUS: 4DATE:
11/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Judy Reyes, RDTIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Regional Director (RD) Judy Reyes. Upon arrival, staff John Burton (JB) took LPA body temperature, asked the infection control questionnaires, and checked LPA in the visitor log book.

LPA toured the facility inside out with JB. COVID posters were observed at main entrance and the facility. Screening station with mask, hand sanitizer, glove, thermometer and visitor log book were observed. Living room, family room, kitchen, dinning room and two restrooms were inspected. All trash cans were observed with covers. Paper towels were observed all with holders. Four resident bedrooms, laundry room, and garage were inspected. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. PPE supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 69 degree F, and hot water temperature was at 120 degree F. Four residents were observed in facility.

Fire extinguisher was serviced on 02/10/2021. The facility was equipped with smoke and carbon monoxide detectors. Fire alarm system was tested, and was working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

RD stated all the residents and staff are fully vaccinated with Pfizer. No deficiency or citation were noted today. Exit interview was conducted with RD. This report was provided to RD for signature. A copy of this report was emailed to RD.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2021
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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