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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708050
Report Date: 02/19/2025
Date Signed: 02/19/2025 02:36:26 PM

Document Has Been Signed on 02/19/2025 02:36 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/
DIRECTOR:		GONZALES, DEBORAHFACILITY TYPE:
741
ADDRESS:373 PINE LANETELEPHONE:
(650) 948-8291
CITY:LOS ALTOSSTATE: CAZIP CODE:
94022
CAPACITY: 250TOTAL ENROLLED CHILDREN: 0CENSUS: 169DATE:
02/19/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Joni TsukimuraTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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On February 19, 2025, at 12:40 PM, Licensing Program Analyst (LPA) Kiran Jain arrived at the facility to conduct a Case Management – Other inspection visit for an suspected elder abuse incident, reported by the facility through SOC 341. Upon arrival, the LPA was greeted by the Assisted Living Director (ALD), Joni Tsukimura. The LPA disclosed the purpose of the visit. The ALD informed the LPA that there were (30) residents in Assisted Living care and total facility census was 169.

On 01/27/2025, the resident (R1) reported an incident to staff member (S2). R1 stated that on 01/25/2025, around 9:00 PM, staff member (S1) assisted them with the shower. After that, S1 helped them to stand at the side of the shower so that R1 could hold onto the rails facing the wall, and S1 then proceeded to dry R1 with a towel. R1 stated that S1 brushed their hand with the towel against R1’s breast. R1 mentioned that it happened a second time and felt more deliberate, so they asked S1 to leave.

On 02/19/2025, at 1:13 PM, LPA interviewed ALD. ALD stated that R1 was not able to describe the person. When ALD initially talked to R1, ALD didn’t have the schedule with them as they were not sure who was working on the Saturday night. ALD stated that they asked R1 to describe the person who could have given them the shower, but R1 was still not able to identify the staff. ALD added that they didn’t go back with a picture to help R1 identify the staff. ALD confirmed that the facility notified the Los Altos Police Department. An officer called back and talked to R1 in the presence of R1’s family member (FMD). The police officer didn’t come to the facility, and no police report or complaint was made. R1 didn’t want to file a police complaint. R1’s family (FM1) was aware of this incident.

On 02/19/2025, at 1:36 PM, LPA interviewed R1’s family member (FMD). FMD stated that R1 was anxious to talk about this incident with the LPA and that R1 had anxiety, with many things for R1 being anxiety-based. FMD mentioned that the staff was amazing and that R1 had built a good rapport with them.

Continued on LIC809-C

April CowanTELEPHONE: (650) 266-8889
Kiran JainTELEPHONE: (650) 416-4836
DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2025
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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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: TERRACES AT LOS ALTOS, THE
FACILITY NUMBER: 430708050
VISIT DATE: 02/19/2025
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FMD stated that R1 never felt that S1’s actions while assisting them with the shower were inappropriate and that, in R1’s mind, they weren’t thinking they were reporting something inappropriate. FMD added that R1 was taken aback when this incident was reported to the police, as it was never an issue that R1 was concerned about. FMD explained that at times, R1’s Parkinson’s-related anxiety took over and that they helped R1 process and dissect the incident, considering it one of those moments. FMD stated that it was just a case of R1 getting used to a new person helping them. There was never anything inappropriate with what S1 did, and according to FMD, S1 had their own style within appropriate boundaries.

No deficiencies were cited during today's visit.

An exit interview was conducted with the Assisted Living Director. A copy of this report was left with the Assisted Living Director, Joni Tsukimura, whose signature on this form confirms receipt of the report.

SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Kiran JainTELEPHONE: (650) 416-4836
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC809 (FAS) - (06/04)
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