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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202196
Report Date: 11/24/2025
Date Signed: 11/24/2025 11:02:17 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/24/2025 11:02 AM - 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:		JOCELYN CANOSAFACILITY TYPE:
734
ADDRESS:15470 LA ALAMEDA DRTELEPHONE:
(408) 779-5353
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 5CENSUS: 4DATE:
11/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Cynthia Octabiano - Interim AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced Required 1 Year visit and met with Interim Administrator (I-ADM) Cynthia Octabiano and stated the purpose of the visit.

The facility serves 5 adults 18 and over with special health care needs who are developmentally disabled and all five may be bedridden. LPA observed 3 staff and 4 residents. LPA observed 4 out of 4 residents are persons with special health needs. 1 Out of 4 is ambulatory, 3 Out of 4 are non-ambulatory.

LPA interviewed I-ADM who stated that ADM Jocelyn Canosa, stepped down as the facility administrator on 09/08/2025. The licensee is in the process of hiring a permanent administrator. I-ADM, has a current administrator certificate.

LPA toured the facility with I-ADM inside and outside. Including but not limited to the kitchen, dining, activity room, 5 resident room, garage, 3 bathroom and exterior perimeter. The exterior perimeter and walkway are free from obstruction/debris. The ramp and back deck are maintained, handrails and ramp is sturdy. Hallways are well lighted and free from obstructions.

LPA observed the kitchen is maintained and organized, food supply for at least 2 days of perishable food and 7 days of nonperishable food, including emergency supply formulas for 7 days. Sharps and medications were locked in secured areas. Cleaning and laundry supplies are in a separate storage and locked under the sink.

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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/24/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 11/24/2025
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LPA inspected 4 residents room and observed rooms are equipped with Hoyer lifts and beds with full bed rails. Residents room have sufficient storage to store personal items.

The facility bathroom are supplied with soap, paper towels, and trash cans with lids. The shower is equipped to serve adults who are non-ambulatory, non-skid mats and grab bars. The water temperature in the bathroom and kitchen are measured at 105.7 to 120 degree F. The facility temperature is at 70 degree F.
LPA measured refrigerator temperature at 38 degree F and freezer measure at 0 degree F.

The facility is equipped with a fire alarm system connected to the fire department, water sprinkler, smoke and carbon monoxide alarm system, 1 generator for emergency purposes.

LPA reviewed facility record, 3 staff and 4 residents records such as but not limited to the resident medications and centrally stored medication and destruction record (CSMDR), and personal and incidental (P&I), appraisal needs and services plan, progress notes, staff training, criminal background clearance and personal rights and mandated reporting. LPA observed records are complete and updated.

The facility earthquake training was last administered on 10/16/25, and fire drill was administered on 11/1/25, the facility conducts fire drill on a monthly basis. Fire extinguisher was last inspected on 01/21/25 and 1/24/25. Generator was last tested on 11/13/2025 and checked every two weeks.

LPA requested updated copies of LIC 500 (personnel summary report), surety bond and LIC 308 (designation of administrator.)

No deficiencies were cited during today's visit based on California Code of Regulation (CCR) Title 22. An exit interview was conducted with interim administrator Cynthia Octabiano and a copy of the report was provided

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end of report
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2025
LIC809 (FAS) - (06/04)
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