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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202113
Report Date: 11/15/2022
Date Signed: 11/15/2022 05:06:24 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/15/2022 05:06 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 - CORTE DE MEDEAFACILITY NUMBER:
435202113
ADMINISTRATOR:FAY CACDACFACILITY TYPE:
735
ADDRESS:1616 CORTE DE MEDEATELEPHONE:
(408) 448-1521
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY: 4CENSUS: 4DATE:
11/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Fay CacdacTIME COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Fay Cacdac. Upon arrival, staff Florentino Cadiqal (S1) took LPA's body temperature, asked the infection control questionnaires, and checked LPA in the visitor log book.

LPA observed the COVID posters at main entrance and in the facility. Screening station with hand sanitizer, thermometer, masks, and visitor log book were observed. LPA toured the facility inside and out with S1. Living room, office, kitchen, dinning room, and 2 restrooms were inspected. All trash cans were observed with covers. All paper towels were observed with holders. There are 4 resident single rooms in facility. 4 residents were observed in facility. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Knives closet, medication closet, and cleaning product closet were observed locked. PPE supplies were observed sufficient. Room temperature was at 68 degree F, and hot water was at 110 degree F.

Fire extinguisher was serviced on 05/05/2022. The facility was equipped with smoke and carbon monoxide detectors. Front yard and backyard were inspected. There was no obstruction observed to block the walkways. ADM stated all the residents and staff are fully vaccinated with Pfizer. The ADM already submitted the Infection Control Plan to LPA.

No deficiency or citation were noted today. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of this report was emailed to ADM
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2022
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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