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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202602
Report Date: 08/18/2022
Date Signed: 08/18/2022 04:35:46 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/18/2022 04:35 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:GARDENS SENIOR CAREFACILITY NUMBER:
435202602
ADMINISTRATOR:ARELLANO, ROSARIOFACILITY TYPE:
740
ADDRESS:1946 COTTLE AVETELEPHONE:
(408) 807-5846
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:6CENSUS: 5DATE:
08/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Rosario ArellanoTIME COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Rosario Arellano. Upon arrival, staff Antonina Ojano (AO) took LPA body temperature, and checked LPA in the visitor log book.

LPA toured the facility inside out 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. Living room, kitchen, dinning room and two restrooms were inspected. All trash cans were observed with covers. Paper towel were observed with holders. Six single resident bedrooms, and laundry room were inspected. One staff live-in rooms was observed in facility. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. PPE supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 71 degree F, and hot water temperature was at 106 degree F in facility. Three staff were observed at facility. 5 residents were observed at facility. Two of the residents are in hospice care, two of them can walk with walker, and one of them is ambulatory.

Fire extinguisher was serviced in April 2022. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

ADM stated all the residents and staff are fully vaccinated and done with booster. 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: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2022
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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