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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202195
Report Date: 11/20/2024
Date Signed: 11/20/2024 05:07:44 PM

Document Has Been Signed on 11/20/2024 05:07 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:
11/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:10 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's Required - 1 Year annual inspection. LPA met with Administrator, Judy Reyes.

During visit, LPA toured the facility to include the kitchen, living room, resident bedrooms, bathrooms, and exterior. LPA observed 4 residents. 3 staff members (1 LVN, 1 CNA, and 1 RN) were present. The 3 staff members are fingerprint cleared and associated to the facility's roster.

All fire exit routes are free and clear of obstruction. Fire extinguisher last serviced on 09/26/2024. Facility has an operable carbon monoxide detector. The facility has a Central Fire Alarm System that is connected to a monitoring vendor which will alert the local fire department in the event of an emergency. The fire alarm system and sprinklers was last serviced on April 2024. The facility has overhead lifts in the resident bedrooms, bathrooms and in the living room area. Facility has an emergency disaster plan last updated in January 2024 which still lists the former Administrator. Fire/Earthquake drills are being conducted at least quarterly. LPA observed 4 out of 4 residents uses oxygen. Facility has a back-up generator which was last serviced on 09/09/2024. Facility staff tests the generator every two weeks for about 15 minutes to ensure it is operable.

Facility temperature maintained at 68 degrees F. Lidded trash bin observed in the kitchen. Sharp objects, chemicals and disinfectants observed locked. Refrigerator temperature maintained at 35 degrees F. Freezer temperature maintained at 0 degrees F. 4 out of 4 residents uses a G-Tube for feeding.

See LIC809-C for additional information.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2024
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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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 - TAYLOR
FACILITY NUMBER: 435202195
VISIT DATE: 11/20/2024
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Resident bedrooms are equipped with beds, night stands, dressers, and adequate lighting. PPE supplies to include gloves and gowns observed. 4 out of 4 residents has an approved exception request from the Department to utilize full bed rails.

Bathrooms supplied with shower beds, grab bars, hygiene supplies, and paper supplies. LPA measured the hot water temperature using a waterproof thermometer and observed the water temperature fluctuates from hot to cold. LPA observed the hot water took about 3-4 minutes to reach 107.6 degrees F and after about 15-20 seconds, the hot water temperature dropped down to about 95 degrees F. After about 2-3 minutes the hot water temperature again increased and stayed at 121.1 degrees F. Administrator states they will place a work order for the hot water.

2 resident files were reviewed and observed complete. 2 residents centrally stored medications and centrally stored medication records were reviewed. LPA observed 6 medications for R1 and 3 medications for R2 were not recorded on the centrally stored medication record. LPA observed the centrally stored medication record were not maintained as the start dates were empty. 2 residents P&I money was inspected and observed complete.

3 staff files were reviewed. 3 staff obtains an up-to-date 1st Aid certification, health screening, TB result, annual staff training, and updated LVN/RN license.

The following documents were requested by 11/22/2024: Emergency Disaster Plan.

LPA requested for the change of Administrator documents by 11/29/2024: Board Letter, LIC500, LIC308, Administrator Certificate or proof of renewal of the Administrator Certificate, Resume, ID/DL, and LIC9182.

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

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/20/2024 05:07 PM - It Cannot Be Edited


Created By: Christine Dolores On 11/20/2024 at 04:40 PM
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 - TAYLOR
FACILITY NUMBER: 435202195

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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
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Based on observation, record review and interview, the licensee did not comply with the section cited above wherein 2 residents centrally stored medications were not part of the centrally stored records which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2024
Plan of Correction
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Licensee will ensure all residents centrally stored medication logs are complete and maintained. Licensee will conduct a training with all staff regarding medications. Licensee will submit a training plan to LPA Dolores via email by POC due date of 11/21/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 11/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2024


LIC809 (FAS) - (06/04)
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