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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200344
Report Date: 09/22/2022
Date Signed: 09/22/2022 12:10:00 PM


Document Has Been Signed on 09/22/2022 12:10 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:FORUM AT RANCHO SAN ANTONIO, THEFACILITY NUMBER:
435200344
ADMINISTRATOR:NANCY KAOFACILITY TYPE:
741
ADDRESS:23500 CRISTO REY DRIVETELEPHONE:
(650) 944-0100
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY:791CENSUS: DATE:
09/22/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Nancy KaoTIME COMPLETED:
12:12 PM
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Licensing Program Analyst (LPA) Ryker Heberle arrived unannounced to conduct a case management visit and met with Administrator Nancy Kao and Director of Resident Services/RCFE Administrator Dana Graefe. The purpose of the visit was to inspect the newly constructed memory care unit on the facility grounds, which goes by the name of Daffodil Ridge Memory Care Unit.

The new memory care unit has an approved fire clearance for 26 non-ambulatory clients. There were no clients observed on site. Facility sketch and exit routes are posted throughout facility, as well as activities schedule and menu.

LPA toured the facility inside and outside including the entry point, activity space, kitchen, 24 bedrooms, 28 bathrooms, staff offices, common dining and activity space, designated activity room, 2 kitchenettes, garage, storage rooms, and patio area. Bedrooms were equipped with proper furniture and lighting. All rooms were noted to be clean and well maintained. Facility windows and window screens all observed to be in good repair. Bathrooms contained paper supplies, hygiene products, and grab bars. Hot water temperature was maintained at 113.5 degrees Fahrenheit. Internal temperature was observed to be maintained at 70-73 degrees Fahrenheit.

Facility is equipped with smoke detectors and fire extinguishers. Fire extinguishers were last inspected in January of 2022. Delayed egress doors were tested and observed to be functioning properly. Hallway and exit routes were free and clear of obstruction. Elevator observed to be in working condition.

Based on overall physical inspection conducted by LPA, the Daffodil Ridge Memory Care Unit is ready for occupancy. Approval of memory care unit raises approved occupancy from 791 to 817. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Nancy Kao and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022
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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