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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202665
Report Date: 07/01/2022
Date Signed: 07/01/2022 04:00:18 PM


Document Has Been Signed on 07/01/2022 04:00 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:LOMA CLARA SENIOR LIVINGFACILITY NUMBER:
435202665
ADMINISTRATOR:DIANA SMITHFACILITY TYPE:
740
ADDRESS:16515 BUTTERFIELD BLVDTELEPHONE:
(669) 258-3500
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY:89CENSUS: 64DATE:
07/01/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Julie MayderTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived at the facility unannounced to open an initial complaint investigation. LPA met with Resident Care Director (RCD), Julie Mayder. During complaint visit, a violation was observed and a case management - deficiencies visit was conducted.

LPA toured the memory care section with RCD.

At 01:44 p.m., LPA observed two out of two resident rooms who require oxygen, without a "No Smoking - Oxygen in use" sign posted in an appropriate area. HSD stated the signs were posted but sometimes the residents like to remove the signs from the wall. LPA advised to place the signs back on the walls.

The facility staff corrected the violation during visit. At 03:45 p.m., , LPA observed the "Oxygen in use" sign posted in an appropriate area outside two out of two resident rooms.

A technical violation was issued per California Code of Regulations, Title 22. No deficiencies were cited.

This report was reviewed with Julie Mayder and a copy of the report was provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2022
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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