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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708724
Report Date: 12/23/2020
Date Signed: 01/04/2021 11:27:46 AM

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:LINCOLN & PINE, WILLOW GLENFACILITY NUMBER:
430708724
ADMINISTRATOR:LIGAYA SEMANAFACILITY TYPE:
740
ADDRESS:1710 LINCOLN AVENUETELEPHONE:
(408) 265-6520
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:6CENSUS: 4DATE:
12/23/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Administrator Mary Rose AcedebeTIME COMPLETED:
12:08 PM
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LPA Steve Nguyen conducted a virtual Technical Assistance with Administrator Mary Rose Abcede. The TA was conducted in order to help facilitate and assist the facility with the latest Covid protocols according to CDC, PHD, and CCLD guidelines.

Per Administrator: Each residents have their own room but do share a common bathroom. Staffing is coverage is maintained and there is an alternate staffing plan in place. Meals are served in resident's room. Currently there are no covid positive case at facility.

LPA toured the facility and inspected: Bedroom, bathroom, backyard, medicine cabinet, cleaning supplies cabinet, front entry doorway, dinning area, kitchen and living room area. All areas were observed well maintained, signage prevalent/ conspicuous, social distancing & PPE were practiced by staff and some residents (due to behaviors).

Administrator was informed that a report of this TA will be forwarded via email for her to review, sign, and return. Also, that a PCC visit will be scheduled at a later date.
SUPERVISOR'S NAME: George NwaforTELEPHONE: (408) 324-2116
LICENSING EVALUATOR NAME: Steve NguyenTELEPHONE: (650) 676-0051
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2020
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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