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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294338
Report Date: 11/03/2022
Date Signed: 11/03/2022 10:47:54 AM


Document Has Been Signed on 11/03/2022 10:47 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 CALIFORNIA GINGER HOMEFACILITY NUMBER:
435294338
ADMINISTRATOR:SPARKS, WILLIAMFACILITY TYPE:
740
ADDRESS:205 GINGER WAYTELEPHONE:
(408) 782-0329
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY:4CENSUS: 4DATE:
11/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Judy ReyesTIME COMPLETED:
10:50 AM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection focusing on infection control. LPA met with Administrator, Judy Reyes.

During visit, LPA toured the facility with staff (S1) to include the living room, kitchen, dining room, resident rooms, bathrooms, garage, and backyard.

Facility temperature maintained at 72 degrees Fahrenheit. All fire exit routes were free and clear of obstruction. All staff observed wearing a face mask. All staff present are fingerprint cleared and associated to the facility.

Facility has a designated entry point for symptoms screening, temperature check, and sign-in. Hand sanitizer made available at entry along with Personal Protective Equipment (PPE) to include gloves and masks. LPA observed facility's PPE supplies. Bathrooms supplied with hand washing sign, hygiene products, and paper supplies. Trash can with lid observed throughout the facility. Facility staff clean and disinfect multiple times daily and as needed. Residents temperature and symptoms are monitored twice daily. Facility staff are trained in infection control. LPA reviewed the facility's procedures to isolation. Staff are N95 fit tested. The following posters observed to include but not limited to social distancing, cover your cough, hand washing, and symptoms of COVID-19.

Documents requested to include the change of Administrator. LPA obtained the LIC610D, LIC500, and proof of Administrator Certification enrollment during visit.

No deficiencies were cited per California Code of Regulations, Title 22. Advisory note provided.

This report was reviewed with Judy Reyes and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022
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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