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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200344
Report Date: 11/10/2020
Date Signed: 11/10/2020 01:25:37 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, THEFACILITY NUMBER:
435200344
ADMINISTRATOR:NANCY KAOFACILITY TYPE:
741
ADDRESS:23500 CRISTO REY DRIVETELEPHONE:
(650) 944-0100
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY:743CENSUS: 58DATE:
11/10/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:28 AM
MET WITH:Rosalie HulogTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Joanne Roadilla conducted an unannounced Case Management tele-visit today. 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 and Assisted Living Manager (ALM) Rosalie Hulog.

The purpose of this case management visit is to gather additional information regarding the self-reported death report of a resident (R1). On 11/09/20, the department received a death report that R1 passed away at the facility premises on 11/06/20.

At around 11:30am, LPA interviewed ALM. Per ALM, the lead care manager (LCM) was the one who found R1 unresponsive in R1’s bed while LCM was doing rounds. 911 was called and CPR was started, paramedics came and continued CPR but was not successful. LPA requested for R1’s records (LIC602 and care plan).

No deficiencies cited during today's tele-visit. Report was discussed with and a copy sent to Rosalie Hulog to sign and mail back to CCL.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne RoadillaTELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2020
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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