<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202194
Report Date: 11/25/2024
Date Signed: 11/25/2024 12:14:41 PM

Document Has Been Signed on 11/25/2024 12:14 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 - DUNNE AVENUEFACILITY NUMBER:
435202194
ADMINISTRATOR/
DIRECTOR:		REYES, JUDYFACILITY TYPE:
735
ADDRESS:275 W DUNNE AVETELEPHONE:
(408) 558-1500
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 4CENSUS: 4DATE:
11/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Jocelyn Canosa. TIME VISIT/
INSPECTION COMPLETED:
12:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual required - 1 year inspection. LPA met with Interim Administrator, Jocelyn Canosa.

During visit, LPA toured the facility with the Administrator to include the kitchen, living room, dining room, resident bedrooms, bathroom, garage, storage unit, and exterior. The storage unit and garage are used for storage items. All fire exit routes were free and clear of obstruction. There was 1 staff and 1 resident present. Staff is fingerprint cleared and associated to the facility.

Facility temperature maintained at 71 degrees F. Resident bedrooms equipped with individual beds, linens, night stands, closet space, and adequate lighting. Resident (R1)'s bed is equipped with half bed rails. Facility was unable to produce the physician's report for the use of half-bed rails for resident (R1). Administrator states R1 uses the half bed rails for mobility. Bathrooms supplied with hygiene products and paper supplies. LPA Dolores did not have a water thermometer during visit. LPA measured the hot water temperature in the bathroom using the facility's water thermometer, which measured at 113 degrees F. Kitchen refrigerator temperature maintained at 32 degrees F and freezer temperature at 0 degrees F. Facility has at least 2 days worth of perishables and 7 days worth of non-perishable foods.

Facility has an infection control plan. LPA observed PPE supplies to include gloves, gowns. Fire extinguisher last serviced on 01/09/2024. Facility has a smoke detector, the last fire inspection was completed in March 2024. See LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 - DUNNE AVENUE
FACILITY NUMBER: 435202194
VISIT DATE: 11/25/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Facility does not have a carbon monoxide detector. Administrator states a plan to purchase and install the carbon monoxide today. Facility has an emergency disaster plan. Emergency drills are conducted quarterly. LPA observed an extra flashlight in the kitchen and office. Facility has an emergency kit located in the garage in which only the Administrator and specific staff has access to. Administrator states either the Administrator or those specific staff are always available to come to the facility in case the items needs to be accessed in the garage.

LPA reviewed 2 resident files and observed the files are complete. 2 residents P&I money was inspected and observed complete.

2 residents centrally stored medications and centrally stored medication records were reviewed. LPA observed 5 medications for R1 did not contain a start date, and R1's over-the-counter cream was not part of the centrally stored medication record. LPA observed the over-the-counter cream has a physician's order and instructions. Administrator was advised to ensure start dates are being completed and all centrally stored medications are inputted in the centrally stored medication record. Administrator states understanding and states a plan to provide in-service training for all staff on medications.

LPA reviewed 2 staff files and observed the files are complete to include a 1st aid certification, fingerprint clearance, health screening, TB result, and job application.

LPA requested for the change of Administrator documents by 12/06/2024: Board Letter, LIC500, LIC308, Administrator Certificate or proof of renewal of the Administrator Certificate, Resume, ID/DL, and LIC9182.

Deficiencies was cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Interim Administrator, Jocelyn Canosa and a copy of the report and appeal rights was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/25/2024 12:14 PM - It Cannot Be Edited


Created By: Christine Dolores On 11/25/2024 at 11:45 AM
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 - DUNNE AVENUE
FACILITY NUMBER: 435202194

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above wherein the facility did not have at least one carbon monoxide detector in the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/26/2024
Plan of Correction
1
2
3
4
Licensee will purchase and install a carbon monoxide today, 11/25/2024. Licensee will submit proof of purchase and a picture of the carbon monoxide detector installed in the facility, to LPA Dolores via email by POC due date of 11/26/2024.
Type A
Section Cited
CCR
80072(a)(8)(B)
Personal Rights
(B) A written order from the client's physician indicating the need for the postural support shall be maintained in the client's record. The licensing agency shall be authorized to require additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review the licensee did not comply with the section cited above wherein the licensee did not obtain a physician's order for the use of R1's half bed rails which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/26/2024
Plan of Correction
1
2
3
4
Licensee will submit a written plan in obtaining a physician's order for R1's half rails, to LPA Dolores via email by POC due date of 11/26/2024.
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:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 11/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/25/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 11/25/2024 12:14 PM - It Cannot Be Edited


Created By: Christine Dolores On 11/25/2024 at 11:52 AM
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 - DUNNE AVENUE
FACILITY NUMBER: 435202194

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(7)
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review the licensee did not comply with the section cited above wherein 1 of R1's medications was not inputted in the centrally stored medication record which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2024
Plan of Correction
1
2
3
4
Licensee will provide an in-service training on centrally stored medcations and records. Licensee will submit the in-service training to LPA Dolores via email by POC due date of 12/02/2024.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 11/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/25/2024


LIC809 (FAS) - (06/04)
Page: 4 of 4