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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200344
Report Date: 01/29/2021
Date Signed: 02/02/2021 01:12:22 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:748CENSUS: 428DATE:
01/29/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Nancy KaoTIME COMPLETED:
03:35 PM
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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 396 to 406 ambulatory residents and from 379 to 383 non-ambulatory residents for a total capacity of 789. LPA conducted a virtual tour of 7 villas, #61, #62, #65, #76, #77, #82 and #83. All villas have two bedrooms and two bathrooms. Per ED, each villa can accommodate up to 2 people.

For all 7 villas, a fire extinguisher located inside the closet by the front door was observed and was last serviced between September 10-11, 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. There is a laundry area adjacent 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 ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne RoadillaTELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2021
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: 01/29/2021
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At around 2:02pm, Villa #61 was inspected. This villa can accommodate ambulatory residents. Hot water temperature in the kitchen was tested and measured at 115.1 degrees F. The alarm by the entry was tested and observed working.

At around 2:16pm, Villa #62 was inspected. This villa can accommodate ambulatory residents. Hot water temperature in master bathroom was tested and measured at 110.3 degrees F. The alarm in bedroom #2 was tested and observed working.

At around 2:29pm, Villa #65 was inspected. This villa can accommodate ambulatory residents. Hot water temperature in the bathroom #2 was tested and measured at 114.9 degrees F. The alarm in the master bedroom was tested and observed working.

At around 2:42pm, Villa #76 was inspected. This villa can accommodate ambulatory residents. Hot water temperature in the kitchen was tested and measured at 114.4 degrees F. The alarm in the den was tested and observed working.

At around 2:52pm, Villa #77 was inspected. This villa can accommodate ambulatory residents. Hot water temperature in bathroom #1 was tested and measured at 117.6 degrees F. The alarm in the living room was tested and observed working.

At around 3:15pm, Villa #82 was inspected. This villa can accommodate non-ambulatory residents. Hot water temperature in the bathroom #2 was tested and measured at 117.6 degrees F. The alarm in the master bedroom was tested and observed working.

At around 3:24pm, Villa #83 was inspected. This villa can accommodate non-ambulatory residents. Hot water temperature in the kitchen was tested and measured at 116.6 degrees F. The alarm between the kitchen and the den was tested and observed working.

Based on overall physical inspection, Villas #61, #62, #65, #76, #77, #82 and #83 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 ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne RoadillaTELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2021
LIC809 (FAS) - (06/04)
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