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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200605
Report Date: 09/22/2022
Date Signed: 09/22/2022 04:20:05 PM


Document Has Been Signed on 09/22/2022 04:20 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: 39DATE:
09/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:21 PM
MET WITH:Kurt GursuTIME COMPLETED:
04:21 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection today and met with Administrator Kurt Gursu (Admin).

LPA entered the facility through designated central point of entry and was screened by staff. Staff, residents in common areas, and visitors were observed to be wearing face coverings. Hand sanitizers, soap, and paper supplies were observed to be available. At least 30 days' supply of personal protective equipment (PPE) was observed to be available in the premises.

LPA toured the facility including 2 dining rooms, 2 medication rooms, activities room, 2 offices, 2 kitchenettes, 2 facility courtyards, and 10 resident bedrooms. Temperature observed between 71*F and 78*F in resident bedrooms. Facility water temperature measured between 112.5*F and 119.7*F. Fire extinguishers were observed to have been last inspected in November of 2021. Facility was observed to have at least 2 days worth of perishable and one week's supply of nonperishable food. All rooms were observed to be clean and well maintained. All emergency exits observed to be free from obstruction. No prohibited items noted in any resident rooms.

The facility has reached a 100% COVID-19 vaccination rate for residents and staff. Smoke and carbon monoxide detectors were observed and confirmed to be operating properly. The facility's infectious control plan has been submitted and is currently under review by the department..

No deficiencies were cited. Exit interview conducted with Administrator Kurt Gursu and a copy of this report was provided during visit.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022
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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