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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202195
Report Date: 08/28/2024
Date Signed: 08/28/2024 02:52:40 PM

Document Has Been Signed on 08/28/2024 02:52 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/
DIRECTOR:
NOBUHLE MANYIKAFACILITY TYPE:
734
ADDRESS:19175 TAYLOR AVETELEPHONE:
(408) 782-0389
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 5CENSUS: 4DATE:
08/28/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:25 PM
MET WITH:Jocelyn Canosa and Judy ReyesTIME VISIT/
INSPECTION COMPLETED:
02:55 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 a case management - incident visit. LPA met with designated Administrator, Jocelyn Canosa and Program Administrator, Judy Reyes.

The purpose of the visit is to follow-up on a telephone call, incident reports, and SOC341s the Department received regarding the residents of the facility.

On 07/22/2024, the Department was notified via telephone call of several past incidents that a staff had recently brought up. These past incidents were brought to the attention of the facility's management on 07/15/2024.

During visit, LPA toured the facility with Administrator and observed 4 residents. Upon arrival, 2 staff members observed working. 3 staff members observed working at 2:30PM. LPA interviewed 2 staff members.

LPA discussed the facility's plan of action. The facility plans to complete training by Friday, 08/30/2024 with all staff. The training topics will include client's rights, HCBS guidelines, special incident reporting, suspected abuse and neglect, and right to prompt medical care and treatment. Administrator will send the training documents to LPA Dolores once completed.

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

This report was reviewed with designated Administrator, Jocelyn Canosa and Program Administrator, Judy Reyes and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2024
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 1