435294338-11-25-2024-26-AS-CDOS-DBCUUQ-20241125145356

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435294338
Report Date: 11/25/2024
Date Signed: 11/25/2024 02:54:04 PM

Document Has Been Signed on 11/25/2024 02:54 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 CALIFORNIA GINGER HOME		FACILITY NUMBER:	435294338
ADMINISTRATOR/ DIRECTOR:	JUDY REYES		FACILITY TYPE:	740
ADDRESS:	205 GINGER WAY		TELEPHONE:	(408) 782-0329
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY: 4	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	11/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:25 PM
MET WITH:	Judy Reyes		TIME 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 the facility's required 1 year annual inspection. LPA met with Administrator, Judy Reyes. During visit, LPA toured the facility with the Administrator to include the kitchen, dining room, resident bedrooms, bathrooms, laundry room, garage, and exterior. All fire exit routes are free and clear of obstruction. There are 3 staff to 3 residents present. All staff are fingerprint cleared. Facility temperature maintained at 68 degrees F. Kitchen is supplied with at least 2 days worth of perishables and 7 days worth of non-perishable foods. Refrigerator temperature maintained at 36 degrees F and freezer temperature at 0 degrees F. Resident bedrooms equipped with individual beds, linens, night stand, closet space, and adequate lighting. Each resident bedroom has overhead lifts. Resident (R1)'s bed is equipped with half bed rails. Facility was unable to produce the physician's report for the use of half-bed rails for resident (R1). Administrator states R1 uses the half bed rails for mobility. Bathroom is equipped with hygiene and paper supplies. LPA Dolores did not have a water thermometer during visit. The Administrator measured the hot water temperature in the bathroom using the facility's water thermometer, LPA observed the hot water is maintained at 108 degrees F. Facility has an infection control plan. LPA observed PPE supplies to include face shields, gloves, and gowns. Facility has an emergency disaster plan. Emergency drills are being conducted quarterly. Facility's fire inspection was completed on 04/10/2024. See LIC809-C.

Sarah Yip	TELEPHONE: (408) 324-2131
Christine Dolores	TELEPHONE: (408) 334-8552
	DATE: 11/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024

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 4

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 CALIFORNIA GINGER HOME	FACILITY NUMBER: 435294338
	VISIT DATE: 11/25/2024

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
26
27
28
29
30
31
32

Fire extinguisher last serviced on 08/12/2024. LPA observed an operable carbon monoxide detector located in the hallway. Emergency bins filled with medical supplies and non-perishable foods observed in the garage. Each resident has a grab and go backpack. LPA observed lanterns (emergency lighting) throughout the facility.

LPA reviewed 2 resident's files are maintained and complete. 2 residents centrally stored medications and centrally stored medication records observed maintained. 2 resident's P&I money was reviewed with the Administrator and all money was accounted for.

LPA reviewed 2 staff files are complete to include a fingerprint clearance, 1st aid certification, health screening, TB result, and job application. The Administrator was unable to produce at least 20 hours of annual training documentation for the 2 staff. The Administrator states plan to ensure all staff completes the required 20 hours of annual training.

Documents were obtained to include the updated liability insurance and LIC500.

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 appeal rights were provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 11/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 11/25/2024 02:54 PM - It Cannot Be Edited

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 CALIFORNIA GINGER HOME	FACILITY NUMBER: 435294338
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interiew and record review the licensee did not comply with the section cited above wherein 2 staff does not have at least 20 hours of annual training in the topics listed in this section which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/02/2024
	Plan of Correction
1 2 3 4	Licensee will remind each staff individually to complete the required 20 hours of training. Licensee will submit a written plan for when all staff will complete the annual training, to LPA Dolores via email by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Sarah Yip	TELEPHONE: (408) 324-2131
Christine Dolores	TELEPHONE: (408) 334-8552
	DATE: 11/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 11/25/2024 02:54 PM - It Cannot Be Edited

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 CALIFORNIA GINGER HOME	FACILITY NUMBER: 435294338
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above wherein the licensee did not obtain a physician's order for R1's half bed rails which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/26/2024
	Plan of Correction
1 2 3 4	Licensee will submit a written plan in obtaining a physician's order for R1's half rails, to LPA Dolores via email by POC due date of 11/26/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Sarah Yip	TELEPHONE: (408) 324-2131
Christine Dolores	TELEPHONE: (408) 334-8552
	DATE: 11/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4