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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202665
Report Date: 10/13/2020
Date Signed: 10/15/2020 09:36:33 AM

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:LOMA CLARA SENIOR LIVINGFACILITY NUMBER:
435202665
ADMINISTRATOR:JOLIE C. HIGGINSFACILITY TYPE:
740
ADDRESS:16515 BUTTERFIELD BLVDTELEPHONE:
(669) 258-3500
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY:89CENSUS: 44DATE:
10/13/2020
TYPE OF VISIT:Case Management - IncidentANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jolie HigginsTIME COMPLETED:
11:42 AM
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Licensing Program Analyst (LPA) Karen Taku conducted an unannounced Case Management Tele-visit, due to COVID-19 preventative measures. LPA spoke with Administrator (Admin) Jolie Higgins.

The purpose of today's visit is to gather additional information regarding the passing of R1. On 10/12/2020, the Department received a Death report indicating R1 passed away on 10/8/2020 and the cause of death is unknown.

During tele-visit, LPA interviewed the Admin and learned R1 passed away at a local hospital on 10/8/2020. The Admin will provide CCL a copy of Death Report upon receipt.

LPA obtained copies of R1's records (Physician's Report and Care Plan).

No deficiencies were cited during today tele-visit. This report was discussed with the Admin and a copy was provided via email for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Karen TakuTELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2020
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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