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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200924
Report Date: 09/12/2024
Date Signed: 09/12/2024 12:46:52 PM


Document Has Been Signed on 09/12/2024 12:46 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:GILROY ELDERLY CARE HOMEFACILITY NUMBER:
435200924
ADMINISTRATOR:CLARK, DINAFACILITY TYPE:
740
ADDRESS:415 LONDON DRIVETELEPHONE:
(408) 847-4645
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:6CENSUS: 3DATE:
09/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Dina ClarkTIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's required - 1 year inspection. LPA met with Administrator, Dina Clark.

During visit, LPA toured the facility with staff to include the living room, kitchen, resident bedrooms, bathrooms, garage, and exterior. All fire exit routes were free and clear of obstruction. Facility staff present are fingerprint cleared and associated to the facility.

Facility temperature maintained at 75 degrees F. Kitchen supplied with at least 2 days worth of perishables and 7 days worth of non-perishable foods. LPA observed the facility has fresh fruits on the kitchen counter to include bananas, oranges, apples, cantaloupe, and watermelon. Refrigerator temperature maintained at 39 degrees F. Freezer temperature maintained at -0 degrees F. Sharp object, chemicals and disinfectants are locked. Lidded trash bin observed in the kitchen. Hot water temperature maintained at 105 degrees F. Resident bathroom equipped with a shower chair, grab bars, and non-slip mats. Bedrooms equipped with beds, linens, dresser, night stands, and adequate lighting. Sliding doors equipped with door alarms and observed clear of obstruction.

LPA observed the facility's prepared emergency supply which includes linens, non-perishable foods, and a first aid kit. Facility has flashlights, lanterns, and batteries in case of an emergency. Facility conducts emergency drills quarterly. Fire extinguisher last serviced on 10/27/2023. Carbon monoxide present and observed operable. Facility has a large plastic bin filled with PPE supplies.

SEE LIC809-C.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: GILROY ELDERLY CARE HOME
FACILITY NUMBER: 435200924
VISIT DATE: 09/12/2024
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LPA reviewed 3 resident files contained an admission agreement, medical assessment, TB result, personal rights, consent forms, and appraisal/needs and services plan. LPA observed 3 resident's appraisal/needs and services plan were not entirely completed. The background information are left blank and the socialization, emotional, and mental needs wrote "NA". LPA advised ADM to complete all sections of the appraisal/needs and services plan to include the background information, socialization, emotional and mental needs.

LPA reviewed 3 staff files contained a 1st aid certification, health screening, TB result, and personnel record. Staff are provided at least 20 hours of annual training to include topics of emergency preparedness, dementia/Alzheimer's, medications, and oxygen use. LPA advised ADM to include at least 4 hours of training on postural supports, restricted health conditions, and hospice care.

Posters observed in the hallways to include but not limited to complaint poster, ombudsman poster, emergency disaster plan, facility license, personal rights, and COVID-19 related resources.

No deficiencies were cited per California Code of Regulations, Title 22. Advisory notes provided.

This report was reviewed with Administrator, Dina Clark and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
LIC809 (FAS) - (06/04)
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