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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202602
Report Date: 08/25/2023
Date Signed: 08/25/2023 11:39:55 AM


Document Has Been Signed on 08/25/2023 11:39 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
CENTRAL COAST CR/RES, 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: 6DATE:
08/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Facility Manager Antonina OjanoTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Facility Manager (FM) Antonina Ojano. .

LPA toured the facility inside out with FM which included; the Living room, kitchen, dinning room, two restrooms and 6 residents bedrooms. The staff area of the facility was also inspected. Front yard and backyard were inspected. There was no obstruction to block the walkways.

Two day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication closet, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 76 degree F, and hot water temperature was measured at 107 degrees F in both resident bathrooms.

Fire extinguisher was serviced in August 2023. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by FM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on August 15 2023.

LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 3 staff (S1 to S3) and 3 residents (R1-R3).

No deficiencies cited during today's visit. This report was reviewed with Facility Manager Antonina Ojano and a copy of the signed report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2023
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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