<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294338
Report Date: 11/24/2021
Date Signed: 11/24/2021 01:51:18 PM

Document Has Been Signed on 11/24/2021 01:51 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:ELWYN NC - GINGER WAYFACILITY NUMBER:
435294338
ADMINISTRATOR:YOUNG, ARMILYNFACILITY TYPE:
740
ADDRESS:3190 S BASCOM AVE., STE. 140TELEPHONE:
(408) 782-0329
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY: 4CENSUS: 4DATE:
11/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:SPARKS, WILLIAMTIME COMPLETED:
02:00 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 conducted an unannounced annual required inspection and met with Administrator William Sparks and Lead House Staff Julieta Ramos.

During visit, LPA toured the facility inside and outside to include living room, hallways, kitchen, resident rooms, shower room, bathroom, garage, and backyard. Fire exits were free and clear of obstruction. Toxins, sharp objects, and medications were locked and secured.

LPA observed a central entry point, screening area, and hand sanitizer for all visitors, residents and staff. All staff were observed wearing a face mask.

The following signs were posted to include: symptoms of COVID, visitor policy, social distancing, limit the spread of germs, hand washing, airborne precautions, and cover your cough. LPA observed the bathroom to have paper supplies and soap available for staff, residents, and visitors. Trash can was observed covered with lid in each resident's room and throughout the facility. LPA observed each resident to have an emergency backpack located in the garage. Facility has a sufficient amount of PPE supplies. Facility disinfect and sanitize high touch surfaces daily and as needed. Facility has a mitigation plan in place to prevent the spread of COVID-19.

Administrator will provide N95 fit testing for all staff.

No deficiencies cited during today's visit per California Code of Regulations, Title 22. Advisory Note Provided.

This report was reviewed with Administrator William Sparks and a copy of this report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 11/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/24/2021
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 1