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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202568
Report Date: 05/10/2022
Date Signed: 05/10/2022 05:10:47 PM


Document Has Been Signed on 05/10/2022 05:10 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,
, 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: 6DATE:
05/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Irish Ladwig and Paul LauronTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit and met with Irish Ladwig Administrator/Licensee and Paul Lauron Facility Manager.

LPA toured the facility inside and out. All fire exit routes were free and clear of obstructions. Fire extinguisher last inspected on 3/22/2022. The facility conducted Quarterly Fire Drill completed today 5/10/2022 with simulated evacuation with residents and staff participation. Sharp objects, toxins, cleaning supplies are secured. Medications are stored in a locked closet in the hallway.

Facility observed to have designated entry point for COVID 19 symptom screening. Hand sanitizer available to visitors and residents. Bathrooms observed to be supplied with hygiene products. Hand Washing signs posted in the bathrooms. Foot operated trash cans were observed in the bathrooms.

COVID 19 signs posted included Visitor Policy, Wear a Mask, Safety First, Stop Screening Checkpoint, Always Wear a Mask, Symptoms of COVID 19, Cough Etiquette and Social Distancing.

LPA reviewed the facility policies and procedures to include screening, visitation, testing, masking, isolation and disinfecting,

No citations were issued per the California Code of Regulations Title 22.

LPA reviewed report with Irish Ladwig Administrator/Licensee and Paul Lauron Facility Manager and a copy provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022
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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