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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708050
Report Date: 11/09/2022
Date Signed: 11/09/2022 04:36:28 PM


Document Has Been Signed on 11/09/2022 04:36 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: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: 174DATE:
11/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Deborah GonzalezTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Administrator Debbie Gonzalez. The purpose of the Case Management visit was to obtain further information regarding the death of resident R1. The Department received the Death Report on 11/04/2022. R1 had a fall in R1's living unit. Facility staff did not witness the fall. However, the resident had a video camera installed in the bedroom that recorded the fall. The Death Report states that the fall contributed to R1's death.

During visit, LPA Marrufo reviewed video recording of the fall and obtained timestamp information regarding the time of the fall and facility staff response time. R1 had triggered R1's emergency pendant after the fall. The timestamp information states that staff entered R1's room to respond to the fall approximately 2 minutes after the fall.

LPA Marrufo obtained copies of R1's Physician's Report. The staff who responded to the fall were not present during visit. LPA Marrufo obtained the contact telephone numbers for 6 staff who responded to the fall.

No deficiencies were cited at this time as per California Code of Regulations TItle 22.

This report was reviewed with Administrator Debbie Gonzalez and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022
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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