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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201413
Report Date: 09/20/2024
Date Signed: 09/21/2024 03:41:38 PM


Document Has Been Signed on 09/21/2024 03:41 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: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: 50DATE:
09/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Diana Jane GutierrezTIME COMPLETED:
02:56 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Director of Community relations Diana (DCR) Jane Gutierrez.

DCR informed that 50 residents and 29 staff in the facility. LPA reviewed 5 resident files and 5 staff files.

LPA toured the facility with DCR. Lobby, common area, activity room, kitchen, dining room, laundry room, Salon room, break room, storage room, and restrooms were inspected. 28 shared resident bedrooms were inspected. 2 bedrooms shared with one restrooms and 1 single room with restroom, 3 common shower rooms and common restrooms were observed. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. The temperature of refrigerator was observed at 40 degree F and the temperature of the freezer was observed at -10 degree F. Medication room was observed locked. Cleaning product room was observed locked. Room temperature was at 70 degree F, and hot water temperature was at 106 degree F in facility.

The emergency call in the resident room was tested and staff came within 1 minute. First aid boxes were observed in the facility.

Fire extinguisher was found expired. The bought new Fire extinguishers and installed them before LPA finished the annual inspection. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors were tested and were observed working. The courtyard and backyard were toured. The last time the facility conducted the fire drill was on 6/18/2024.

No citation were noted today. Exit interview was conducted with DCR. This report was provided to DCR for signature. A copy of the reports was provided to DCR.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024
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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