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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708050
Report Date: 08/03/2020
Date Signed: 08/03/2020 04:49:19 PM

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:TERRACES AT LOS ALTOS, THEFACILITY NUMBER:
430708050
ADMINISTRATOR:GONZALES, DEBORAHFACILITY TYPE:
741
ADDRESS:373 PINE LANETELEPHONE:
(650) 948-8291
CITY:LOS ALTOSSTATE: CAZIP CODE:
94022
CAPACITY:250CENSUS: 166DATE:
08/03/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Deborah GonzalesTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management - Incident Visit over telephone and spoke with Deborah Gonzales. The visit was conducted over telephone due to the ongoing COVID-19 Shelter-in-Place order throughout the county and state. The Case Management - Incident Visit was due to an Incident Report that the facility filed with CCL on 07/27/2020. The Incident Report stated that resident R1 had reported to R1's hospice nurse that a facility staff had handled R1 roughly, causing R1 to fall, resulting in discoloration on the right side of R1's head. The facility also filed an SOC341 report for the incident.

During visit, LPA spoke with Administrator Deborah Gonzales. Administrator Gonzales stated that she had conducted an investigation with R1 and R1 had been inconsistent in R1's account of the alleged incident. Per Administrator Gonzales, R1 was not able to identify if the staff who allegedly pushed R1 was male or female and was not able to provide a date for when the incident occurred. Administrator Gonzales stated that R1 reported to forget to no longer be able to ambulate and sometimes gets up to walk without assistance and falls.

LPA Marrufo requested R1's physician's report, care plan, and emergency contact information form.

No deficiencies were cited as per California Code of Regulations - Title 22.

This report was reviewed with Administrator Deborah Gonzales. A copy of the report will be sent to Administrator Gonzales to review, sign, and return.
SUPERVISOR'S NAME: George NwaforTELEPHONE: (408) 324-2116
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2020
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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