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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202125
Report Date: 02/28/2024
Date Signed: 02/28/2024 05:10:20 PM

Document Has Been Signed on 02/28/2024 05:10 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:
02/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Carolyn ParadelaTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Carolyn Paradela, Administrator.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo observed the facility kitchen area had locked drawers for medications, cleaning supplies, and sharp objects. LPA Marrufo observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. The first aid kit was inspected and found to be complete.

LPA Marrufo toured two out of two bathrooms and observed the water temperatures to be 108 F and 109 F. Each bathroom has working lights and available soap and paper towels.

LPA Marrufo toured 5 out of 5 resident bedrooms and observed each bedroom to have functioning lights and available bedding and clothing storage areas.

LPA Marrufo tested the carbon monoxide detector and found it to function properly when tested. LPA Marrufo reviewed the Smoke Detector Inspection Report that stated the smoke detector system was last tested on 11/13/2023. The Emergency Disaster Drill Log stated the last drill was conducted on 01/01/2024.


LPA Marrufo reviewed resident and staff records, including Personal and Incidental Money Logs and Centrally Stored Medication Logs, and found them to be complete.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Carolyn Paradela and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2024
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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