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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708817
Report Date: 09/22/2023
Date Signed: 09/22/2023 04:58:36 PM


Document Has Been Signed on 09/22/2023 04:58 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
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: 284DATE:
09/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:Jud SevernsTIME COMPLETED:
10:39 AM
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Licensing Program Analyst (LPA) Steve Chang conducted a Case Management - Incident investigation visit to deliver the investigation finding and met with Executive Director Jud Severns (ED).

On 07/05/2023, the Department received a death report of resident R1 from the facility that R1 was found dead at R1's bathroom on 07/01/2023.

On 7/6/2023, R1's physician report and appraisal Needs and Service Plan were obtained. On the same day, LPA interviewed Resident Service Director (RSD). RSD stated on 07/01/2023, R1 was found on the floor of the bathroom and was unresponsive. 911 was called immediately. Paramedics came and announced R1 passed away.

During 7/6/2023 and 9/12/2023, investigation was conducted. Based on the reviews of R1's medical records, the cause of the death of R1 was heart attack disease.

Based on the interviews conducted and documents reviewed, R1's direct cause of death was heart disease. No deficiency or citation were issued today.

Exit interview was conducted with ED. The report was provided to ED for signature. A copy of the report was provided to ED.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023
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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