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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708817
Report Date: 12/26/2024
Date Signed: 12/26/2024 03:04:35 PM

Document Has Been Signed on 12/26/2024 03:04 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:TERRACES OF LOS GATOS, THEFACILITY NUMBER:
430708817
ADMINISTRATOR/
DIRECTOR:		PETER MORRISFACILITY TYPE:
741
ADDRESS:800 BLOSSOM HILL ROADTELEPHONE:
(408) 356-1006
CITY:LOS GATOSSTATE: CAZIP CODE:
95032
CAPACITY: 458CENSUS: 168DATE:
12/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Residential Living Director Sandra MirasolTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analysts (LPAs) Marcela Yanez and Manuel Monter conducted an unannounced Required 1 Year visit and met with Sandra Mirasol, Residential Living Director (RLD). LPAs stated the purpose of the visit.

LPAs toured Assisted Living building with RLD inside and out, which include upstairs and downstairs. LPAs randomly inspected the following, but not limited to resident bedrooms: 45,47, 60, 66,70,and 72 LPAs randomly tested 4 resident bedrooms water with thermometer and measured range from 116.0 to 118.0 degrees F. LPAs also inspected the dining area and kitchen of the Assisted Living building. LPAs observed the kitchen area LPAs observed perishable food supply of at least two days and a non-perishable food supply of at least seven days. No obstructions were noted during tour.

LPAs toured the Memory Care building inside and out. LPAs randomly inspected the following, but not limited to resident bedrooms: 1,2,3,4,5 and 9. LPAs randomly tested 6 bedrooms water temperature with thermometer and measured to range from 110.0 to 115 degrees F. LPA tested delayed egress doors which activated auditory sound when pressed.

LPAs toured the Independent Living with RLD inside and out which included 3 floors and multiple different buildings. LPAs randomly toured the following, but not limited to, resident bedrooms: M151, M153, M154,M155, Q66,M355, and P397.

LPA observed fire extinguisher was last serviced on 04/16/2024. LPA reviewed Fire and Earthquake log. the last Drill was last conducted on 12/06/2024. Facilities Sprinkler system was last inspected on 09/06/2024

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE: DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/26/2024
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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, THE
FACILITY NUMBER: 430708817
VISIT DATE: 12/26/2024
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LPA reviewed resident records for 10 residents.. LPA reviewed 5 staff records and found them to be complete. LPAs interviewed 13 residents and 3 staff.

LPA provided RLD with a flyer "Important updates to Dementia Care & Miscellaneous Changes, Effective January 1, 2025."

LPA requested a copy of the following documents:
1.LIC 500, Personnel Summary 2. LIC 308, Designation of Administrative Responsibility
3.LIC400, Affidavit Regarding Client/Resident Cash Resources 4. Liability Insurance
5. Qualifications of Administrator (Certificate)
6. Please review your facility program for updates (incorporating new laws and/or regulations)

No deficiency were cited as per California Code of Regulations Title 22. This report was reviewed with Residential Living Director Sandra Mirasol and a copy of this report and appeal rights were provided.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
LIC809 (FAS) - (06/04)
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