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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201413
Report Date: 10/25/2024
Date Signed: 10/25/2024 12:42:32 PM


Document Has Been Signed on 10/25/2024 12:42 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: 53DATE:
10/25/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Administrator Debbie CotaTIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management visit in regards an incident report, which stated a resident had struck another resident. LPA's met with Administrator Administrator Debbie Cota. LPA's explained the purpose of the visit.

On October 23, 2024, the Department received an incident report, regarding resident R1. The incident report stated on October 22, 2024, at approximately 7:15pm, resident R2 was upset at the front desk. R2 was pushing the front desk computer and was aggressive with staff when re-direction was attempted. Resident R1 was nearby and saw what was happening and became upset. R1 got up and slapped R2 in the face. Both residents were separated. No physical harm was note on R2's face. The incident report states that staff S1 and S2 were present during the alleged slap.

On October 25, 2024, LPA Manuel Monter interviewed resident R1 and R2. Resident R1 was asleep and could not be interviewed during LPA's visit. Resident R2 stated he/she does not remember the slapping incident that occurred on October 22, 2024.

LPA interviewed staff S1. S1 stated he/she was getting ready to clocked out and was at the front desk, while staff S2, was working at the front desk. S1 stated resident R1 was sitting on a grey chair, 5 feet away from the front desk. S1 stated he/she observed resident R2 walk from the dinning room towards the front desk, and was upset. S1 stated R2 began to make a commotion and was pushing the monitors. S1 stated he/she attempted to de-escalate R2. S1 stated R1 then suddenly stood up and slapped R2. S1 stated after being slapped, R2 calmed down and S2 escorted R2 towards his/her bedroom.

Staff S1 stated resident R1 and R2 did not have an argument or altercation earlier that day.
Haven't seen any physical altercations between them in the past.
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SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
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 CENTER
FACILITY NUMBER: 435201413
VISIT DATE: 10/25/2024
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LPA interviewed ADM. ADM stated R1 and R2 do not have a history of fighting with each other. ADM stated R1 likes to sit in the front desk area, away from the other residents. ADM stated R1 does not enjoy R2's company due to being intrusive, such as trying to helpful. ADM stated she submitted updated care plans for both residents to CCL.

Based on record review, Residents R1 and R2 have Neurocognitive disorder.

LPA determined that the above incident does not require further investigation.

This report was reviewed with Administrator Debbie Cota and a copy of the report was provided.

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SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC809 (FAS) - (06/04)
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