435200344-6-5-2020-26-AS-JROA-BQAUE4-20200605153031

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435200344
Report Date: 06/05/2020
Date Signed: 06/05/2020 03:30:49 PM

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:	FORUM AT RANCHO SAN ANTONIO, THE		FACILITY NUMBER:	435200344
ADMINISTRATOR:	NANCY KAO		FACILITY TYPE:	741
ADDRESS:	23500 CRISTO REY DRIVE		TELEPHONE:	(650) 944-0112
CITY:	CUPERTINE	STATE: CA	ZIP CODE:	95014
CAPACITY:	741	CENSUS: 417	DATE:	06/05/2020
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Nancy Kao		TIME COMPLETED:	02:00 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) Joanne Roadilla conducted a tele-inspection visit today via FaceTime. The Department has suspended on site visits due to COVID-19 shelter in place order by Governor Newsom. LPA spoke to Executive Director (ED) Nancy Kao. The facility has applied for an increase in capacity from 388 to 390 ambulatory residents. The facility has an approved fire clearance for 390 ambulatory and 353 non-ambulatory residents. At 1:30pm, LPA conducted a virtual tour of Villa 67 inside and out. Per ED, Villa 67 can accommodate up to 2 people. The villa has 2 bedrooms. Both bedrooms have bathrooms with adequate lighting and grab bars in the shower. Hot water temperature in the master bathroom was tested and measured at 117.5 degrees F. Hot water temperature in the second bathroom and kitchen were also tested and measured at 116.4 degrees F and 116.7 degrees F respectively. Windows in both bedrooms and in the living room area were checked to be in good repair. Living room double doors lead out to the patio. Common areas were observed to have adequate lighting. Thermostat at the facility registered the room temperature at 77 degrees F. The fire extinguisher was last serviced on April 2020. The kitchen and dining room were inspected. Refrigerator/freezer was observed in good working condition. Continued on 809-C, page 2.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne Roadilla	TELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2020

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: FORUM AT RANCHO SAN ANTONIO, THE	FACILITY NUMBER: 435200344
	VISIT DATE: 06/05/2020

NARRATIVE

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Combination smoke and carbon monoxide detectors were observed in both bedrooms, the den as well as in the hallway by the main living room. The alarm in the den was tested and observed working. A laundry area with washer, dryer and a storage space were observed by the hallway leading from the kitchen to the garage. Garage was observed empty and free of obstruction. The Villa’s outside grounds including the patio was observed clear and free of tripping hazard.

Based on overall physical inspection, this villa is ready for occupancy. Exit interview conducted with and copy of report sent to Nancy Kao to mail back to CCL.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne Roadilla	TELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2020

LIC809 (FAS) - (06/04)

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