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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202580
Report Date: 05/26/2020
Date Signed: 05/28/2020 03:37:18 PM

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:WILLOW OAKS SENIOR CARE HOMEFACILITY NUMBER:
435202580
ADMINISTRATOR:ABLAO, VICKYFACILITY TYPE:
740
ADDRESS:1573 WILLOW OAKS DRIVETELEPHONE:
(408) 267-5729
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:6CENSUS: 6DATE:
05/26/2020
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Agnes Teodoro-AdministratorTIME COMPLETED:
05:00 PM
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On 5/26/2020, Licensing Program Analyst (LPA) Maria Kamara conducted an Unannounced Case Management Legal / Non-compliance Inspection visit via tele-conference video call with the facility, spoke with Administrator Agnes Teodoro and was informed of the purpose for the call. LPA Maria informed Administrator Agnes that due to the current COVID-19 "shelter in place" the Department is currently conducting tele-conference call in the place of an on site visit.

At 2:10PM, LPA and Administrator Agnes toured the facility. The capacity/census at the facility is 6/6. There were three caregivers present during the call. LPA Maria did a wellness check on the residents and were interviewed. Three caregivers including the administrator were interviewed. Residents stated they doing fine and everything is ok at the facility with the "shelter in place". LPA observed "COVID-19" postings, hygiene products and staffs stated they are following hygiene protocols.

Medications, Sharps and toxic materials were observed to be well secured and separately locked. 2-day perishable and 7-day non-perishable food supply was observed to be sufficient and properly stored. No medications were observed unlocked.

At 3:40PM, Staff and resident files were reviewed and audited. Residents personal rights protocols were discussed by LPA and the Administrator.

The stipulations discussed during Non-compliance meeting on August 1, 2019 were reviewed to ensure that the facility is in continuous compliance of their corrective action plans on the following items such as medication storage, Residents Personal Rights and Medications and Bio hazard. destruction/disposal procedure. No deficiency resulted from today's inspection.
Exit interview was conducted with Administrator Agnes Teodoro. LPA informed Agnes that a copy of the signed LIC809 by LPA Maria will be emailed to: anneteodoro@icloud.com for signature and the original mailed to CCLD office.
SUPERVISOR'S NAME: George NwaforTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Maria KamaraTELEPHONE: (650) 388-2295
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2020
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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