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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708817
Report Date: 10/06/2020
Date Signed: 02/03/2021 02:44:46 PM

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:TERRACES OF LOS GATOS, THEFACILITY NUMBER:
430708817
ADMINISTRATOR:BURGOYNE, BRADLEYFACILITY TYPE:
741
ADDRESS:800 BLOSSOM HILL ROADTELEPHONE:
(408) 356-1006
CITY:LOS GATOSSTATE: CAZIP CODE:
95032
CAPACITY:458CENSUS: DATE:
10/06/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:11 PM
MET WITH:Bradley BurgoyneTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Karen Taku conducted an unannounced Case Management Tele-visit, via IPhone due to COVID-19 preventative measures. LPA met with Resident Services Director Sandy Marisol.

The purpose of today's visit is to gather additional information regarding R1's death. On 9/30/2020, the Department received a Death Report, indicating R1 had passed away on 9/26/20. The death report indicated that R1 was found on right side and unconscious.

LPA interviewed the RSD.

LPA obtained copies of documents for R1. No deficiencies were cited during today's visit.

This report was discussed with the Admin and a copy was provided via email for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Karen TakuTELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2020
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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