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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201413
Report Date: 09/20/2022
Date Signed: 09/20/2022 04:49:27 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/20/2022 04:49 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
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: DATE:
09/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:16 PM
MET WITH:Debbie CotaTIME COMPLETED:
04:23 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Debbie Cota. Upon arrival, front desk staff took LPA body temperature, asked the infection control questionnaires, and checked LPA in the visitor log book.

LPA toured the facility with ADM. COVID posters were observed at main entrance and the facility. Screening station with masks, hand sanitizer, thermometer and visitor log book was observed at the main entrance. Common area, activity room, kitchen, dining room and restrooms were inspected. All trash cans were observed with covers. Paper towel were observed with holder. 29 shared resident bedrooms were inspected. The beds in shared rooms were 6 feet apart. 2 bedrooms shared with one restrooms were observed. Some restrooms were observed without the posters of hand washing for 20 seconds. It was corrected before LPA finished the report. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. PPE supplies were observed sufficient. Medication room was observed locked. Cleaning product room was observed locked. Room temperature was at 73 degree F, and hot water temperature was at 110 degree F in facility.

Fire extinguisher was serviced on 06/28/2022. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors.

ADM stated all the residents and staff are fully vaccinated and done with booster. ADM stated the Infection Control Plan was submitted to CCL office.

No citation were noted today. Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2022
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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