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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201057
Report Date: 04/21/2023
Date Signed: 04/21/2023 12:30:49 PM


Document Has Been Signed on 04/21/2023 12:30 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:SARATOGA RETIREMENT COMMUNITYFACILITY NUMBER:
435201057
ADMINISTRATOR:SARAH STELFACILITY TYPE:
741
ADDRESS:14500 FRUITVALE AVENUETELEPHONE:
(408) 741-7100
CITY:SARATOGASTATE: CAZIP CODE:
95070
CAPACITY:418CENSUS: 285DATE:
04/21/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Sarah StelTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - incident visit. LPA met with Executive Director (ED) Sarah Stel.

The purpose of the visit was to follow-up on an incident and death report received for resident (R1) who resided in the independent living section. On 04/19/2023, R1 passed away by possible carbon monoxide poisoning. R1 was found by a family member who called 911. Upon arrival of the paramedics, R1 was pronounced deceased.

During visit, LPA was accompanied by ED and another staff to observe the exterior part of the cottage where R1 passed away. LPA interviewed 2 staff members (S1 - S2).

LPA obtained documents to include the resident roster, staff roster, R1's face sheet (admission record), reported incident, and physician's report. Based on record review, R1 was diagnosed with a chronic degenerative disease.

This case management - incident visit will be pending investigation.

This report was reviewed with Executive Director (ED) Sarah Stel 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: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023
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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