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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202125
Report Date: 03/27/2023
Date Signed: 03/27/2023 03:39:49 PM

Document Has Been Signed on 03/27/2023 03:39 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 - SOUTH HENRY AVENUEFACILITY NUMBER:
435202125
ADMINISTRATOR:ROBA ABUSHAABANFACILITY TYPE:
734
ADDRESS:373 S HENRY AVETELEPHONE:
(408) 247-4180
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY: 5CENSUS: 5DATE:
03/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Carolyn ParadelaTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 - Year visit and met with Carolyn Paradela.

During visit, LPA Marrufo toured the facility inside and out. The kitchen area was observed to have food supplies in the refrigerator and pantry areas. There was a perishable food supply of at least 2 days and a non-perishable food supply of at least 7 days. A first aid kit was observed to be complete. Medications were observed to be in a locked cabinet.

Two out of two bathrooms were observed to have available soap, paper towels, and grab bars. The water temperatures in the bathrooms were 116 F and 119 F.

5 out of 5 resident bedrooms were observed. Each bedroom had available bedding, drawers, and functioning lights. The carbon monoxide detector in the hallway was tested and found to be functioning properly. The outdoor area was toured and the exits were clear of obstructions.

LPA Marrufo reviewed facility records. 3 out of 5 residents had Personal and Incidental Money logs and their logs were found to be complete when reviewed. LPA Marrufo reviewed the Centrally Stored Medication Logs for 5 out of 5 residents. Residents R1 and R2 had medications that had been entered without prescription numbers.

A deficiency was cited as per California Code of Regulations Title 22. This report was reviewed with Carolyn Paradela and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2023
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 03/27/2023 03:39 PM - It Cannot Be Edited


Created By: David Marrufo On 03/27/2023 at 03:19 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 - SOUTH HENRY AVENUE
FACILITY NUMBER: 435202125

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(7)(E)


This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in 2 out of 5 resident's Centrally Stored Medication Logs, which poses a potential health rirk to residents in care.
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2023
Plan of Correction
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Licensee agrees to correct all Centrally Stored Medication Logs with missing prescription numbers and conduct in-service training for all staff who record medication information. The Licensee agrees to submit copies of corrected Centrally Stored Medication logs and logs of in-service training of staff to CCL by POC date.
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:Sarah Yip
LICENSING EVALUATOR NAME:David Marrufo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2023


LIC809 (FAS) - (06/04)
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