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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202568
Report Date: 05/20/2021
Date Signed: 05/20/2021 11:15:30 AM

Document Has Been Signed on 05/20/2021 11:15 AM - 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,
, CA
FACILITY NAME:COMPASSIONATE ELDERCARE UNDAJON RCFEFACILITY NUMBER:
435202568
ADMINISTRATOR:MONGEON,JEANETTEFACILITY TYPE:
740
ADDRESS:683 UNDAJON DRIVETELEPHONE:
(408) 914-1147
CITY:SAN JOSESTATE: CAZIP CODE:
95133
CAPACITY: 6CENSUS: 5DATE:
05/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Irish LadwigTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) David Marrufo conducted a Required Annual visit and met with Licensee Irish Ladwig.

LPA Marrufo toured the facility including hallway, outdoor area, kitchen, garage, 5 out of 5 bedrooms, and 2 out of 2 bathrooms. LPA Marrufo also observed PPE storage area.

All staff members were observed to be wearing masks. LPA observed visitor check in area at the single facility entrance and COVID-19 related signs posted throughout the facility. Facility screening questionnaire was completed with Licensee. All restrooms were observed to be adequately stocked with paper towels, hand sanitizer, and hand soap. Restrooms were observed to have a waste basket with pedal operated lid.

Facility observed to have adequate supply of PPEs.

This report was reviewed with Licensee Irish Ladwig and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2021
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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