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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200605
Report Date: 03/02/2021
Date Signed: 03/04/2021 09:03:21 AM

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: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: DATE:
03/02/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Kurt GursuTIME COMPLETED:
11:00 AM
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LPA Steve Nguyen, CDPH Health Facilities Evaluator Nurse (HFEN) Janet Hayes, conducted a tele-visit with Executive Director, Kurt Gursu. The tele-visit consisted of a virtual tour of the facility and LPA advised Kurt the purpose of the visit was to provide the facility guidance and assistance regarding COVID-19 positive status of facility.

The tour showed that the facility (main building) had sufficient COVID-19 signage throughout the facility. Restroom were observed maintained, with; hand washing signs, soap and with paper towels. Hand sanitizing is made available to staff and residents. Observed sign in forms, screening questionnaire and temperature check (with digital thermometer) station at front entrance (main building). Facility has PPE supplies that are available to staff/ residents. All staff were observed wearing face masks. LPA observed house keepers cleaning facility while conducting virtual tour. House keepers are using EPA approved disinfectant and all chemicals are locked away while not in use. Staff encourages residents to social distance and the usage of designated seating is in effect throughout Assisted Living.

CDPH/ HFEN does not have any recommendation at this time.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Steve NguyenTELEPHONE: (650) 676-0051
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE:
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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