<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708817
Report Date: 12/28/2021
Date Signed: 12/28/2021 03:55:39 PM

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: 280DATE:
12/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Sandra MirsolTIME COMPLETED:
03:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Marybeth Donovan conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit and met with Sandra Mirasol Resident Services Director and Martin Knoll Resident Services Manager.

LPA toured the facility inside and out to include entrance, Galleria area, dining area, mail room, activity rooms, bathrooms, salon, and exterior. All fire exit routes were free and clear of obstructions.

Facility observed to have designated entry point for COVID 19 symptom screening with questionnaire. Bathrooms observed to be supplied with hygiene products and hand washing signs. Hand sanitizer available to residents and visitors throughout the facility.

LPA reviewed the facility policies and procedures to include screening, visitation, isolation, disinfecting, sick leave polices, training, supplies, PPE usage, and Fit Testing. All staff are Fit Tested.

No citations issued per the California Code of Regulations Tittle 22.

LPA reviewed report with Sandra Mirasol Resident Services Director and Martin Knoll Resident Services Manager and a copy of this report emailed due to technical issues.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1