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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202568
Report Date: 05/14/2024
Date Signed: 05/14/2024 05:08:09 PM


Document Has Been Signed on 05/14/2024 05:08 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: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:
05/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Irish Ladwig - LIcenseeTIME COMPLETED:
05:00 PM
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On 5/14/2024 at 2:30 P.M. Licensing Program Analyst (LPA) Maria (Mita) Partoza arrived at the facility and conducted an unannounced required 1 year annual inspection and was greeted by the house manager (HM) Paul Jester Lauron. Licensee (LIC) Irish Ladwig came to the facility and met with the LPA to continue with the annual required 1 year inspection. LPA stated the purpose of the visit.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed to serve ages 60 and over 6 non-ambulatory, 1 out 6 may be bedridden and approved for 1 hospice care. The facility's ha 6 residents (R1 to R6) that have neurocognitive impairment. 2 staff were present at the time of the visit. 5 residents were present at the facility and 1 out of 6 is attending a day program. LPA observed 2 out of 5 residents are in the living room and 3 out of 5 are in their bedroom.

At 3:00 p.m. LPA with HM toured the facility inside and outside, including but not limited to the kitchen, dining room, bathroom, living room, resident's rooms, office area, backyard and garage. LPA observed 2 days of perishable food and the refrigerator temperature is at 38 degree F and freezer at 0 degree F. LPA observed that the kitchen, dining room, and living area are accessible and are free of debris at the time of the inspection. LPA observed that knives are in a locked cabinet and not accessible to residents in care.

LPA observed, that the laundry area is in the garage. The garage stores the cleaning supplies, laundry detergents and other chemicals. The garage has a separate storage for 7 days of non-perishable food. The door to access the garage has lock and remained locked during the time of inspection.

Due to time constraint the 1 year required visit will be continued at a later date. No deficiencies is cited during today's visit per California Code of Regulation (CCR) Title 22. An exit interview was conducted with licensee Irish Ladwig. A copy of the report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria PartozaTELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024
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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