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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202725
Report Date: 02/22/2022
Date Signed: 02/25/2022 07:58:13 AM


Document Has Been Signed on 02/25/2022 07:58 AM - 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,
, CA



FACILITY NAME:WILLOW GLEN SENIOR LIVINGFACILITY NUMBER:
435202725
ADMINISTRATOR:JOEY CERVANTESFACILITY TYPE:
740
ADDRESS:2991 FAIRCLIFF CTTELEPHONE:
(408) 914-1147
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:6CENSUS: 5DATE:
02/22/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Irish LadwigTIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted a Technical Assist (TA) Visit via FaceTime platform with Irish Ladwig Licensee and Jackie Jin Licensing Program Manager to provide technical assistance to prevent and mitigate the spread of COVID 19 in the facility. LPA conducted a virtual tour of the facility.

During today's TA-Visit, recommendations were discussed as follows:

1. Remove cloth towels from bathrooms and use paper towels for hand drying
2. Recommended face shields with foam head bands be used one time only due to contamination

Report reviewed with Irish Ladwig Licensee and a copy emailed for signature.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2022
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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