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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202725
Report Date: 06/26/2020
Date Signed: 06/26/2020 06:07:05 PM

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:WILLOW GLEN SENIOR LIVINGFACILITY NUMBER:
435202725
ADMINISTRATOR:LADWIG, JUVELYN IRISHFACILITY TYPE:
740
ADDRESS:2991 FAIRCLIFF CTTELEPHONE:
(408) 914-1147
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:6CENSUS: 4DATE:
06/26/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Irish LadwigTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Joanne Roadilla conducted an unannounced Case Management tele-visit today. The Department has suspended on site visits due to COVID-19 shelter in place order by Governor Newsom. LPA spoke to Administrator (ADM) Irish Ladwig.

On 6/26/20, the department received a death report for resident (R1) who was found unconscious at the facility at around 7am on 6/24/20. The facility called 911 and medical team declared R1's death.

ADM confirmed that R1 was found unconscious in R1's room and 911 was called. Law enforcement and coroner also arrived at the facility and R1's family member was also informed.

LPA requested that ADM send a copy of R1's Physician's Report (LIC602) and Appraisal/Needs and Services Plan (LIC625) for review.

This case management will be kept open pending document review and the coroner's report.

No deficiencies cited during today's tele-visit. Report was discussed with and a copy sent to Irish Ladwig to sign and mail back to CCL.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne RoadillaTELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2020
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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