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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202195
Report Date: 11/24/2021
Date Signed: 11/24/2021 02:50:59 PM

Document Has Been Signed on 11/24/2021 02:50 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 - TAYLORFACILITY NUMBER:
435202195
ADMINISTRATOR:YOUNG, ARMILYNFACILITY TYPE:
734
ADDRESS:19175 TAYLOR AVETELEPHONE:
(408) 782-0389
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 5CENSUS: 2DATE:
11/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:OCTABIANO, CYNTHIA TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Christine Dolores conducted an unannounced annual required inspection and met with Administrator, Cynthia Octabiano.

During visit, LPA toured the facility inside and outside to include kitchen, living room, dining room, hallways, resident rooms, shower room, bathroom, garage, and backyard. Fire exits were free and clear of obstruction.

LPA observed a central entry point, screening area, and hand sanitizer for all visitors, residents and staff. All staff was observed wearing a face mask.

The following signs were posted to include: symptoms of COVID, visitor policy, social distancing, limit the spread of germs, and hand washing. Facility has a designated visitation area. LPA observed the bathroom to have paper supplies and soap available for staff, residents, and visitors. Trash cans were observed covered with lid. LPA observed each resident to have an emergency backpack located in the garage. Facility has a sufficient amount of PPE supplies. Facility disinfect and sanitize high touch surfaces daily and as needed. All staff are N95 fit tested.

Administrator will submit facility's Mitigation Plan by 12/1/2021.

No deficiencies cited during today's visit per California Code of Regulations, Title 22.

This report was reviewed with Administrator Cynthia Octabiano and a copy of this report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 11/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/24/2021
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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