435202196-1-15-2026-26-AS-RMAO-DQGUJS-20260119143759

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202196
Report Date: 01/15/2026
Date Signed: 01/15/2026 10:21:36 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/09/2025 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20250909092939

FACILITY NAME:	ELWYN NC - LA ALAMEDA		FACILITY NUMBER:	435202196
ADMINISTRATOR:	JOCELYN CANOSA		FACILITY TYPE:	734
ADDRESS:	15470 LA ALAMEDA DR		TELEPHONE:	(408) 779-5353
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY:	5	CENSUS: 3	DATE:	01/15/2026
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator Cynthia Octabiano		TIME COMPLETED:	10:20 AM

ALLEGATION(S):

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Resident sustained unexplained injury while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Administrator Cynthia Octabiano

On September 9, 2025 the Department received a complaint alleging Resident sustained unexplained injury. It has been alleged that Resident R1 sustained an unexplained bruise, which was observed on September 8, 2025.

On September 17, 2025, the Department received an incident report regarding R1. The report stated on September 8, 2025, around 2:30pm, it was reported that R1 has a bluish discoloration on his/her chest area. R1’s chest area with bluish discoloration measures about 9 cm X 20 cm. No swelling was noted or signs of pain or discomfort when the area was touched. R1 taken to urgent care for further evaluation.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 26-AS-20250909092939

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/15/2026

NARRATIVE

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On September 17, 2025, LPA Christine Kabariti interviewed staff S1-S2. S1 stated he/she first observed a bluish discoloration on R1’s Chest on Sunday, September 7, 2025. S1 assessed R1 for pain and stated there was nothing unusual. S1 stated he/she was first informed by facility LVN, who reported it to S1. S1 stated he/she informed the PM staff to endorse the bruising to the NOC shift. On September 8, 2025, when he/she arrived to work the discoloration was still there. S1 stated he/she is unsure how R1 sustained the bruising on his/her chest area. S1 denied any falls or unusual incidents that may have occurred. S1 states there is no movement or behaviors R1 has that may have contributed to the bruising on R1's chest.

S2 stated that on September 6, 2025, none of the staff reported any incidents nor did S2 observe any unusual incidents involving R1. S2 stated the day was normal and R1 seemed normal. S2 states no incidents was reported during transports. On September 8, 2025, S2 arrived to work around 6:30am. S2 didn't observe the bruising on R1's chest because he/she wasn't assigned to assist R1. S2 only observed the bruise when ADM Jocelyn Canosa asked him/her about it. S2 was unsure how R1 sustained the bruising on his/her chest. S2 stated, he/she thinks the bruising was sustained because R1 would stretch his/her arms and then smack his/her closed fist on his/her chest. S2 stated that sometimes he/she'll see R1 smack his/her chest with his/her fist and the noise is loud. S2 stated when R1 does that, they'll verbally tell him/her to slow down. S2 stated this is R1's first time sustaining a bruise on his/her chest.

On September 17, 2025, LPA Christine Kabariti interviewed facility Administrator (ADM) Jocelyn Canosa. ADM states there was a bruise on his/her chest area observed by the AM and PM shift on 09/08/2025. ADM states they don't know exactly how R1 got the bruise. ADM stated R1 was also having fluid secretions and rapid heart breath. ADM states on 09/08/2025, R1 was admitted to the hospital. In the ER they did a chest xray, blood work, nose swab and COVID test and they were all negative. ADM stated R1’s Chest xray was normal.

ADM thinks that because R1 was not feeling well due to his/her cold, R1 was stretching his/her arms behind his/her head to allow his/her lungs to expand to breathe better. ADM stated R1 will sometimes would flare his/her arms and hit his/her chest with his/her arms. ADM stated they believe this is how he/she has the bruise. ADM states the staff did not report any falls or unusual incidents during transports. ADM states R1 uses a seat belt while in wheelchair. ADM stated R1 does not use chest straps. ADM stated they transport R1 using a sling and a device that is mounted on the ceiling that lifts the resident. ADM stated the sling does not attach or touch his/her chest. ADM stated R1 has tendencies to flare his/her arms and legs and slap his/her arms on his/her chest. ADM stated this is the first time R1's had a bruise on his/her chest area.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 26-AS-20250909092939

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/15/2026

NARRATIVE

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On January 2, 2026, LPA Manuel Monter interviewed staff S3 and S4. S3 stated he/she wasn’t in the home when R1’s bruises were discovered. S3 stated he/she did not observe anything unusual such as bruising or R1 sustaining a fall in the first week of September 2025. S3 stated R1 does have a behavior of hitting him/herself when upset. S3 stated R1 will raise his/her hands to his/her chest making contact. S3 stated R1 has this behavior occurs on a daily basis. S4 stated he/she wasn’t working at the facility when the alleged bruising occurred. S4 stated he/she has not seen R1 engaging in self injurious behaviors.

LPA Manuel Monter attempted to interview resident R1. R1 did not respond to questions posed to LPA and did not provide any relevant information regarding the allegation.

On January 7, 2026, LPA Manuel Monter interviewed staff S5 and S6. Staff S5 and Staff S6 stated they both worked at the facility the first two weeks of September 2025. Both S5 and S6 stated they did not observe R1 experiencing a fall or anything out of the ordinary, prior to the bruising being discovered on September 8, 2025. Staff S5 stated he/she has not observed R1 having self injurious behaviors, such as hitting his/her chest. Staff S6 stated he/she has observed R1 showing hitting his/her chest with his/her arms. S6 stated this behavior occurs once or twice a month.

On January 7, 2025, LPA Manuel Monter interviewed Witness W1. W1 stated he/she is not aware of R1 having any self injurious behaviors. W1 stated he/she met with the home and based on their discussions believe R1 may have had an accident. W1 stated R1 may have pulled his/her G-tube, resulting in the bruising. W1 stated the home is now actively observing R1 to see if this is a new behavior.

On January 12, 2026, LPA Manuel Monter interviewed staff S7 and S8. S7 stated he/she was working was working at the first 2 weeks of September 2025. S7 stated didn’t see any bruising prior to September 8, 2025. S7 stated he/she didn’t see anything out of the ordinary regarding R1 a week prior to September 8, 2025. Staff S7 and S8 stated they have not observed R1 exhibiting self-injurious behaviors. S8 stated he/she remembers seeing bruising on R1, in September 2025 but doesn’t recall when he/she observed it.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 26-AS-20250909092939

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/15/2026

NARRATIVE

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The Department reviewed R1’s Nursing notes. Note dated September 8, 2025, states, at 3:00pm, R1 was noted to have bluish discoloration in the chest area measuring 9cm by 20cm with some irregular shape. Nursing notes dated September 1-7, 2025, do not note any observation of bruising and note under skin integrity, "no concern".

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. Although R1 sustaining a bruise is a fact, there is not a preponderance of evidence to prove that the allegation that neglect/lack of supervision did or did not occur.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026

LIC9099 (FAS) - (06/04)

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