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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202724
Report Date: 08/19/2021
Date Signed: 08/23/2021 10:26:40 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:GOLDWOOD SENIOR CARE HOMEFACILITY NUMBER:
435202724
ADMINISTRATOR:JEANETTE MONGEONFACILITY TYPE:
740
ADDRESS:2692 GOLDWOOD CTTELEPHONE:
(669) 234-3544
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY:6CENSUS: 6DATE:
08/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Juvelyn Irish Ladwig and Justin LadwigTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit and met with Licensee Juvelyn Irish Lagwig and Justin Lagwig.
LPA toured the facility inside and out to include the entry, bedrooms, bathrooms, kitchen, dining room, living room and exterior. All fire exit routes were free and clear of obstructions. Medications are stored in locked cabinet in the kitchen. Toxins, cleaning supplies, knives and sharp objects are secured.

Facility observed to have designated entry point for COVID 19 symptom screening. Bathrooms observed to be supplied with hygiene products. Hand washing signs were posted in bathrooms. LPA observed supply of Personal Protective Equipment (PPE).

LPA reviewed the facility policies and procedures to include screening, visitation, isolation, disinfecting, staffing, training, supplies, PPE usage and social distancing.

No citations were issued per the California Code of Regulations, Title 22.

LPA reviewed report with Licensee Juvelyn Irish Ladwig and Justin Lagwig and a copy provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021
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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