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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708817
Report Date: 03/09/2021
Date Signed: 03/09/2021 10:20:47 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
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: 238DATE:
03/09/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Bradley BurgoyneTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) David Marrufo and HFEN Nurse Irene Thibault conducted a tele-visit via Zoom to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility. LPA Marrufo, and HFEN Nurse Irene Thibault met with Administrator Bradley Burgoyne and Infection Prevention Leader Diana Tran.

The Administrator reports that there are currently 0 COVID-19 positive residents and 0 COVID-19 positive staff.

During today's tele-visit, the following recommendations were made to the facility by HFEN Nurse Irene Thibault:

1. PPE Donning/Doffing Poster needs to be placed by all PPE stations and storage areas
2. Ensure public seating areas are modified to only permit social distanced seating only

No deficiencies were cited as per California Code of Regulations, Title 22.

This report was reviewed with with Administrator Bradley Burgoyne. A copy of the report will be sent to him for it to be signed and returned to CCL.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2021
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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