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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201413
Report Date: 12/30/2020
Date Signed: 12/31/2020 05:18:17 PM

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: 44DATE:
12/30/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Debbie CotaTIME COMPLETED:
11:45 AM
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Licensing Program Analyst Joanne Roadilla and Health Facilities Evaluator Nurse (HFEN) Emma Erickson from the California Department of Public Health, conducted a tele-visit via Zoom to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility. LPA and HFEN met with Administrator Debbie Cota.

Per ADM, a representative from the California Department of Public Health - Healthcare-Associated Infections Program and a representative from the Santa Clara County Department of Public Health conducted a site visit today and provided guidance on proper infection control and every day protective measures to help mitigate the spread of COVID-19 at the facility.

At around 11:20am, the facility was toured. COVID-19 postings were visible throughout the facility. During the tele-visit, HFEN did not find any areas of concern with infection control practices to prevent, contain, and mitigate the spread of COVID-19. ADM was advised to post donning and doffing posters outside of each room that has a positive case.

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: 12/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2020
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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