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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202195
Report Date: 11/03/2022
Date Signed: 11/03/2022 12:13:35 PM

Document Has Been Signed on 11/03/2022 12:13 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 - TAYLORFACILITY NUMBER:
435202195
ADMINISTRATOR:YOUNG, ARMILYNFACILITY TYPE:
734
ADDRESS:19175 TAYLOR AVETELEPHONE:
(408) 782-0389
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 5CENSUS: 5DATE:
11/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Nobuhle ManyikaTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection focusing on infection control. LPA met with Administrators Nobuhle Manyika and Jocelyn Canosa.

During visit, LPA toured the facility with staff (S1) to include the living room, kitchen, dining room, resident rooms, bathrooms, garage, and backyard.

Facility temperature maintained at 71 degrees Fahrenheit. All fire exit routes were free and clear of obstruction. All staff observed wearing a face mask. All staff present are fingerprint cleared and associated to the facility.

Facility has a designated entry point for symptoms screening, temperature check, and sign-in. Hand sanitizer made available at entry along with Personal Protective Equipment (PPE) to include masks. LPA observed facility's PPE supplies and emergency supplies. Bathrooms supplied with hand washing sign, hygiene products, and paper supplies. Trash can with lid observed throughout the facility. Facility staff clean and disinfect multiple times daily and as needed. Residents temperature and symptoms are monitored three times daily. A couple facility staff are trained on infection control. LPA reviewed the facility's procedures to isolation. Staff will renew N95 fit-test annually. The following posters observed to include but not limited to social distancing, cover your cough, droplet precaution, hand washing, and symptoms of COVID-19.

Documents requested to include the change of Administrator. LPA obtained the LIC610D, LIC500, and R1's Incident Report during visit.

No deficiencies were cited per California Code of Regulations, Title 22. Advisory notes provided.

This report was reviewed with Nobuhle Manyika and Jocelyn Canosa and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2022
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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