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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201413
Report Date: 09/14/2021
Date Signed: 09/15/2021 10:37:47 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: 46DATE:
09/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Debbie CotaTIME COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced infection control site visit. LPA met with the Administrator Debbie Cota.

One central entry point was designated for all staff, residents, and visitors. A temperature screening station, questionnaire, and sign in sheet were present at the entrance. LPA was temperature checked and screened before entering.

LPA toured the facility. The facility was observed to be in sanitary condition. All staff members and visitors were observed to be wearing masks. There were COVID-19 signs and hand sanitizer at the entrance and throughout the facility.

LPA inspected 2 restrooms. The restrooms were observed to be adequately stocked with paper towels, hand soap, and covered trash bins. Hand washing signs were present. Hand washing sign was also posted in the kitchen to remind the kitchen staff to wash their hands before handling food. There was an adequate supply of personal protective equipment in the storage areas.

LPA discussed the infection control with Administrator. LPA reviewed the current Provider Information Notice PIN 21-40-ASC with Administrator. All residents and all staff were fully vaccinated and required so according to facility's policy.

No deficiency cited during visit.

This report was reviewed with Administrator. A copy of this report were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
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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