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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201413
Report Date: 12/10/2020
Date Signed: 12/11/2020 09:25:02 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:CEDAR CREEK ALZHEIMER'S & DEMENTIA CARE CENTERFACILITY NUMBER:
435201413
ADMINISTRATOR:DEBBIE COTAFACILITY TYPE:
740
ADDRESS:15245 NATIONAL AVENUETELEPHONE:
(408) 356-5636
CITY:LOS GATOSSTATE: CAZIP CODE:
95032
CAPACITY:58CENSUS: 48DATE:
12/10/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Debbie CotaTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Joanne Roadilla conducted an unannounced Case Management tele-visit today. The Department has suspended on site visits due to COVID-19 shelter in place order by Governor Newsom. LPA spoke to Administrator (ADM) Debbie Cota.

The purpose of the tele-visit was to inquire about an incident that was reported on 12/08/20 of an alleged sexual abuse of a resident. Adult Protective Services (APS) and Long Term Care Ombudsman (LTCO) were notified.

At around 2:55pm, LPA interviewed ADM regarding the incident and requested for resident's records for review.

This case management will be kept open pending subsequent interviews and additional report.

No deficiencies cited during today's tele-visit. Report was discussed with and a copy sent to Debbie Cota to sign and mail back to CCL.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne RoadillaTELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2020
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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