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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708817
Report Date: 10/02/2024
Date Signed: 10/02/2024 10:50:44 AM


Document Has Been Signed on 10/02/2024 10:50 AM - 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:TERRACES OF LOS GATOS, THEFACILITY NUMBER:
430708817
ADMINISTRATOR:GREGORY BEARCEFACILITY TYPE:
741
ADDRESS:800 BLOSSOM HILL ROADTELEPHONE:
(408) 356-1006
CITY:LOS GATOSSTATE: CAZIP CODE:
95032
CAPACITY:458CENSUS: 270DATE:
10/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Peter MorrisTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Administrator Peter Morris. The purpose of the visit was to follow up on a Death Report submitted to the Department on 05/21/2024. The Death Report stated that resident R1 was found deceased on 05/20/2024 at approximately 08:00 AM. The Death Report stated that R1 had complained of neck pain as well as having experienced vomiting and a headache at 12:01 AM on 05/20/2024. The Death Report states R1 was offered to call 911 but R1 refused. R1 was observed deceased in R1's bed at around 08:00 AM.

During today's visit, LPA Marrufo interviewed staff S1 and S2. S1 stated to have received a call from R1's spouse on 05/20/2024 stating that R1 appeared deceased. S1 stated to have entered R1's living unit and observed R1 to be laying on R1's bed with R1's feet touching the floor and R1's back resting on pillows and blankets. S1 stated 911 was called and firemen, paramedics, and police arrived. S1 stated police approved of the removal of R1's body from the facility.

S2 stated during interview that the facility has not received a coroner's report.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Administrator Peter Morris and a copy of this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2024
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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