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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202112
Report Date: 11/15/2024
Date Signed: 11/15/2024 04:47:17 PM

Document Has Been Signed on 11/15/2024 04:47 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:ELWYN NC - WELLINGTON PARKFACILITY NUMBER:
435202112
ADMINISTRATOR/
DIRECTOR:		FAY CACDACFACILITY TYPE:
735
ADDRESS:4865 WELLINGTON PARK DRTELEPHONE:
(408) 281-1116
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 4CENSUS: 4DATE:
11/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Fay CacdacTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Fay Cacdac.

Two staff and one residents were observed in the facility. The other 3 residents went to day program. One staff (S1) was found not associated with the facility. ADM stated he/she requested Human Resource Department to transfer him/her from other ELWYN facility before.

License, personal rights posts were observed in the facility. ADM certificate was observed expired on 10/26/2024. Administrator provided the document for the renewal of ADM certificate. LPA reviewed 2 staff files and 2 resident files.

LPA toured the facility inside out with ADM. Living room, kitchen, dinning room and two restrooms were inspected. Four resident bedrooms, laundry room, and garage were inspected. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. The temperature of the refrigerator was observed at 42 degree F, and the temperature of the freezer was observed at 0 degree F. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 69 degree F, and hot water temperature was at 108 degree F.

Fire extinguisher was serviced on 02/17/2024. The facility was equipped with smoke and carbon monoxide detectors. ADM tested carbon monoxide detectors and it was working fine. First aid box was observed in the facility. Emergency light system and flash lights were observed in the facility. ADM showed the dimmer light system in the facility hallway. Front yard and backyard were inspected. There was no obstruction to block the walkways. One storage room was observed at the backyard.
Deficiencies were noted today. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of this report was provided to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
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 11/15/2024 04:47 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 11/15/2024 at 01:23 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ELWYN NC - WELLINGTON PARK
FACILITY NUMBER: 435202112

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80019(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review, the licensee did not comply with the section cited above in that a staff S1 was found not associated with the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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Administrator stated to submit a plan of correction by the POC due date to ensure all staff are associated with the facility prior to work for the facility.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Romeo Manzano
LICENSING EVALUATOR NAME:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2024


LIC809 (FAS) - (06/04)
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