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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708724
Report Date: 11/07/2024
Date Signed: 11/07/2024 03:26:51 PM

Document Has Been Signed on 11/07/2024 03:26 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:LINCOLN & PINE, WILLOW GLENFACILITY NUMBER:
430708724
ADMINISTRATOR/
DIRECTOR:
LIGAYA SEMANAFACILITY TYPE:
740
ADDRESS:1710 LINCOLN AVENUETELEPHONE:
(408) 265-6520
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
11/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Gladys Smart-Lead StaffTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Marcela Yanez and Manuel Monter conducted an unannounced annual inspection visit, and met with Gladys Smart . During the visit, LPA observed 6 residents and 2 staff. LPA explained the purpose of the visit.

LPA toured the facility inside out with S1 which included the Living room, kitchen, dining room, 2 restrooms and 5 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways. LPAs also toured the garage which is being used as a storage space.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 108 degrees F in bathroom #2, 105 degrees F in Old kitchen sink, 120 degrees F in bathroom #1, and 106 degrees in new kitchen.

Fire extinguisher was serviced on 06/18/24 The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by S2 and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on 08/24/24

LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 2 residents.

No deficiencies cited during today's visit. This report was reviewed with Gladys Smart and a copy of the signed report was provided.
Romeo ManzanoTELEPHONE: (650) 388-2297
Marcela YanezTELEPHONE: (279) 789-1062
DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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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