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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202670
Report Date: 12/18/2024
Date Signed: 12/18/2024 04:50:29 PM

Document Has Been Signed on 12/18/2024 04:50 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:SILICON VALLEY SENIOR CARE HOMEFACILITY NUMBER:
435202670
ADMINISTRATOR/
DIRECTOR:		LADWIG, JUVELYN IRISHFACILITY TYPE:
740
ADDRESS:5255 RAFTON DRTELEPHONE:
(408) 677-4405
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
12/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Irish LadwigTIME VISIT/
INSPECTION COMPLETED:
04:37 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection, and met with Administrator (ADM) Irish Ladwig

3 staff and 6 residents were observed in the facility. 3 resident files and 3 staff files were reviewed.

License, ADM certificate, and personal rights posters were observed in the facility.

LPA toured the facility with ADM inside and out. LPA toured living room, dinning area, laundry room, garage, and kitchen. There are 3 restrooms for residents, 1 restroom for staff, 1 restroom for visitor, 1 staff live-in room, and 5 resident rooms in facility. Two days perishable foods and seven day nonperishable foods were observed sufficient. Room temperature was observed at 72 degree F, hot water temperature was observed at 119 degree F. Medication cabinet, Knife closet were observed locked. Dish washing solution products was observed unlocked on the top of the sunk in the kitchen. ADM locked it immediately during LPA's visit. The facility was equipped with smoke and carbon monoxide detectors. Smoke detector alarm system and carbon monoxide detectors were tested, and were working. Fire extinguisher was serviced on 3/6/2024.

ADM provided 5 residents document for usage of bed rails. First aid box, night lights and flash lights were observed in the facility. The last time the facility conducted the fire drill was on 10/29/2024.

Front yard and backyard were inspected. 3 big storage rooms were observed at the backyard.

Deficiency noted today. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of this report was provided to ADM.
Romeo ManzanoTELEPHONE: (408) 277-1289
Chihhsien ChangTELEPHONE: (408) 904-9843
DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2024
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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Document Has Been Signed on 12/18/2024 04:50 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: SILICON VALLEY SENIOR CARE HOME
FACILITY NUMBER: 435202670

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in that 1 Out of 3 residents files was observed the centrally stored medication form was not matched with the medications which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2024
Plan of Correction
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Administrator stated to provide submit plan of correction and provide staff training for medication to ensure to maintain accurate of centrally stored medication form with resident medications. Administrator agreed to submit the staff training log to CCL office.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo ManzanoTELEPHONE: (408) 277-1289
Chihhsien ChangTELEPHONE: (408) 904-9843

DATE: 12/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2024

LIC809 (FAS) - (06/04)
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