435200344-12-16-2020-26-AS-JROA-BWD3HZ-20201216171642

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435200344
Report Date: 12/16/2020
Date Signed: 12/16/2020 05:17:10 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) 944-0100
CITY:	CUPERTINO	STATE: CA	ZIP CODE:	95014
CAPACITY:	748	CENSUS: 415	DATE:	12/16/2020
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Nancy Kao		TIME COMPLETED:	03:45 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 met with Executive Director (ED) Nancy Kao and Director of Plant Operations Steven Parker. The facility has applied for an increase in capacity from 391 to 396 ambulatory residents and from 357 to 375 non-ambulatory residents for a total capacity of 771. LPA conducted a virtual tour of 8 villas #66, #70, #71, #72, #73, #74, #75 and #81. All villas have two bedrooms and two bathrooms. Per ED, each villa can accommodate up to 2 people. For all eight villas, a fire extinguisher located inside the closet by the front door was observed and was last serviced on September 11, 2020. The closet had a sign to notify residents where the fire extinguisher is located. A thermostat was observed by the living room for regulated temperature at the home. Combination smoke and carbon monoxide detectors were observed in the bedrooms, the den as well as in the hallways. Bedrooms and bathrooms were observed with adequate lighting and grab bars in the shower and an alarm system inside the bathrooms. The windows in the bedrooms and the living room were randomly checked to be in good repair. Living and dining rooms were observed to have adequate lighting. The kitchen had new appliances and there is a laundry area next to the kitchen. Garage was observed empty and the villa’s outside grounds including the patio/courtyard were observed clear and free of any tripping hazard. Continued in 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: 12/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2020

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: 12/16/2020

NARRATIVE

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At around 2pm, Villa #75 was inspected. This villa can accommodate non-ambulatory residents. Hot water temperature in the kitchen was tested and measured at 116.2 degrees F. The alarm in the master bedroom was tested and observed working. This villa was installed with strobe lights for resident who is hearing-impaired. ED verified that fire marshal has inspected this unit and approved the strobe lights.

At around 2:25pm, Villa #74 was inspected. This villa can accommodate non-ambulatory residents. Hot water temperature at the master bathroom was tested and measured at 119.1 degrees F. The hallway alarm by the kitchen was tested and observed working.

At around 2:35pm, Villa #73 was inspected. This villa can accommodate non-ambulatory residents. Hot water temperature in bathroom #2 was tested and measured at 109.7 degrees F. The alarm in the living room area was tested and observed working.

At around 2:42pm, Villa #72 was inspected. This villa can accommodate non-ambulatory residents. Hot water temperature in the master bedroom was tested and measured at 111.3 degrees F. The alarm in the guest bedroom was tested and observed working.

At around 2:52pm, Villa #71 was inspected. This villa can accommodate non-ambulatory residents. Hot water temperature in the kitchen was tested and measured at 116.0 degrees F. The alarm inside the den was tested and observed working.

At around 3:05pm, Villa #70 was inspected. This villa can accommodate non-ambulatory residents. Hot water temperature in bathroom #2 was tested and measured at 113.3 degrees F. The alarm in the entry was tested and observed working.

Continued on 809-C page 3.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne Roadilla	TELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2020

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: 12/16/2020

NARRATIVE

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At around 3:15pm, Villa #81 was inspected. This villa can accommodate non-ambulatory residents. Hot water temperature in the master bathroom was tested and measured at 115.7 degrees F. The alarm in the guest bedroom was tested and observed working.

At around 3:30pm, Villa #66 was inspected. This villa can accommodate ambulatory residents. Hot water temperature in the laundry area was tested and measured at 116.9 degrees F. The alarm in the entry closest to the front door was tested and observed working.

Based on overall physical inspection, Villas #66, #70, #71, #72, #73, #74, #75 and #81 are ready for occupancy. Exit interview conducted with and copy of report sent to Nancy Kao to sign and 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: 12/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2020

LIC809 (FAS) - (06/04)

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