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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200605
Report Date: 09/10/2024
Date Signed: 09/10/2024 02:58:11 PM


Document Has Been Signed on 09/10/2024 02:58 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:ATRIA WILLOW GLENFACILITY NUMBER:
435200605
ADMINISTRATOR:GURSU, UGUR (KURT)FACILITY TYPE:
740
ADDRESS:1660 GATON DRTELEPHONE:
(408) 266-1660
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:63CENSUS: 49DATE:
09/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ugur (Kurt) GursuTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPAs) Marcela Yanez and Manuel Monter conducted an unannounced annual inspection visit, and met with Trevor Treadwill Resident Services Director. LPA explained the purpose of the visit.

LPA toured the facility inside out with Resident Service Director Trevor Treadwill which included the activity, kitchen, dining room, restrooms in Assisted Living CE1, CE9, CE5, CE25, CE24, and Memory Care MC22-25. The staff area of the facility was also inspected. The Facility grounds were inspected. There was no obstruction to block the walkways. While touring the memory care unit, LPA's observed residents in a circle in the backyard doing exercises with staff.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was a 72 degrees F, and hot water temperature was measured to range 106-114 degrees F in Memory Care and Assisted Living bathrooms.

Fire extinguisher was serviced in August, 2024. The facility was equipped with Centralized Sprinkler System was tested on 06/24/2024 and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on 08/28/2024.

LPA reviewed facility records for 4 staff and 5 residents. LPAs reviewed 4 resident medications and centrally stored medication records. LPA conducted interviews with 4 staff and 5 residents.

No deficiencies cited during today's visit. This report was reviewed with Administrator Ugur (Kurt) Gursu and a copy of the signed report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Marcela YanezTELEPHONE: (279) 789-1062
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024
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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