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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202196
Report Date: 11/20/2024
Date Signed: 11/20/2024 02:56:25 PM

Document Has Been Signed on 11/20/2024 02:56 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 - LA ALAMEDAFACILITY NUMBER:
435202196
ADMINISTRATOR/
DIRECTOR:		NOBUHLE MANYIKAFACILITY TYPE:
734
ADDRESS:15470 LA ALAMEDA DRTELEPHONE:
(408) 779-5353
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 5CENSUS: 2DATE:
11/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Jocelyn CanosaTIME VISIT/
INSPECTION COMPLETED:
03:00 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 Interim Administrator, Jocelyn Canosa.

During visit, LPA toured the facility to include the living rooms, kitchen, resident bedrooms, bathrooms, and exterior. LPA observed 2 residents. 2 staff members (1 LVN and 1 PT) were present and 1 respiratory therapist present only during the beginning of the visit. The 3 staff members are fingerprint cleared and associated to the facility's roster. During visit, a musician arrived to the facility to play music for the residents.

All fire exit routes are free and clear of obstruction. Fire extinguisher last serviced on 01/19/2024. 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 was last serviced on 11/14/2023. The facility has overhead lifts in the resident bedrooms, bathrooms and in one of the living room area. Facility has an emergency disaster plan last updated on 10/01/2023 which still lists the former Administrator. LPA advised the Administrator to review and update the emergency disaster plan. Fire/Earthquake drills are being conducted at least quarterly. LPA observed 2 out of 2 residents uses oxygen. Facility has a back-up generator which was last serviced on 09/09/2024. Facility staff tests the generator weekly for about 15 minutes to ensure it is operable.

Facility temperature maintained at 70 degrees F. Lidded trash bin observed in the kitchen. 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 - LA ALAMEDA
FACILITY NUMBER: 435202196
VISIT DATE: 11/20/2024
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The kitchen drawer that contains sharp objects was not observed locked. Administrator was advised to ensure all sharp objects are secured. LPA observed 2 residents present in the living room who are wheelchair bound and requires total assistance. The cabinet which contains chemicals and disinfectants observed locked. Refrigerator temperature maintained at 36 degrees F. Freezer temperature maintained at 0 degrees F. 2 out of 2 residents uses a G-Tube for feeding. Bathrooms supplied with shower beds, grab bars, hygiene supplies, and paper supplies. Bathroom hot water temperature maintained at 104.7 and 110.6 degrees F. Administrator was advised that the hot water temperature should be at least 105 degrees F and not more than 120 degrees F. Resident bedrooms are equipped with beds, night stands, dressers, and adequate lighting. PPE supplies to include gloves and gowns observed. 2 out of 2 residents has an approved exception request from the Department to utilize full bed rails and seat belt while in wheelchair.

2 resident files were reviewed and observed complete. 2 residents centrally stored medications and centrally stored medication records were reviewed and observed maintained with all medication accounted for. 2 residents P&I money was inspected and observed complete.

2 staff files were reviewed. 2 staff obtains an up-to-date 1st Aid certification, health screening, TB result, annual staff training, and updated LVN/PT 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.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Interim Administrator, Jocelyn Canosa and a copy of the report 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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