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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708454
Report Date: 01/22/2025
Date Signed: 01/22/2025 12:58:51 PM

Document Has Been Signed on 01/22/2025 12:58 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:SARATOGA ADULT CARE CENTERFACILITY NUMBER:
430708454
ADMINISTRATOR/
DIRECTOR:		SUSAN HUFFFACILITY TYPE:
775
ADDRESS:19655 ALLENDALE AVENUETELEPHONE:
(408) 868-1262
CITY:SARATOGASTATE: CAZIP CODE:
95070
CAPACITY: 30CENSUS: 9DATE:
01/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Administrator, Rajvir KaurTIME VISIT/
INSPECTION COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced annual inspection and met with Administrator Rajvir Kaur. Saratoga Adult Care Center serves clients 60 years and older, between the hours of 9:00AM to 5:00PM. LPA toured the interior and exterior of the facility with ADM to include the kitchen, office, resident lounge, dining room, bathrooms, back and front of the facility. All exit and passageways were free and clear of obstruction.

LPA oured the kitchen area and observed a perishable food supply and a non-perishable food supply. LPA observed the refrigerator thermometer at 37 degrees F and the freezer thermometer at 0 degrees F. LPA observed the knives storage area, and cleaning product storage area are locked and inaccessible to clients in care. LPA measured hot water temperature in 2 out of 2 client bathrooms at 106.1 degrees F.

LPA observed the facility's smoke and carbon monoxide detectors were inspected on 11/4/2024, Fire extinguishers were last serviced on 3/13/2024. LPA reviewed the facility first aid kit, and it was observed to be complete. The facility emergency drill log was reviewed, the last drill was conducted on 10/17/2024. LPA advised ADM that disaster drills shall be conducted at least every six months, documented and the documentation maintained in the day program for at least one year.

LPA reviewed 5 resident records. 5 out of 5 resident records were found to be complete. Resident records included emergency contact information, physician’s report, appraisal/needs and service plans, and personal rights.

During resident record review, LPA observed documentation for Resident R3, who had a fall while at the facility on 1/1/2025. ADM stated the facility did not know to report the incident by phone or fax to the Department.

See LIC809C

SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE: DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2025
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: SARATOGA ADULT CARE CENTER
FACILITY NUMBER: 430708454
VISIT DATE: 01/22/2025
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LPA advised ADM that a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition a written report must also be submitted within within seven days following the occurrence of the event. ADM stated understanding. ADM sent in a written report of R3's fall to the Department during today's visit.

LPA reviewed 4 staff records. 3 out of 4 staff records were found to be complete. Staff records included fingerprint background clearance, medical assessment with TB result, personnel record and staff training. LPA observed Staff S1's file did not contain a TB result. ADM stated the TB result documentation was in a locked office, and is unable to access the documentation. LPA advised ADM that all personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. ADM stated understanding. ADM states she will submit S1's TB result documentation to the Department by 1/24/25.

No deficiencies were cited during today’s visit per California Code of Regulations Title 22. Two technical violations were issued see LIC9102 for more information. An exit interview was conducted with ADM Rajvir Kaur. A signed copy of this report and was provided.

SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
LIC809 (FAS) - (06/04)
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