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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202725
Report Date: 07/19/2023
Date Signed: 07/19/2023 02:30:32 PM


Document Has Been Signed on 07/19/2023 02:30 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:WILLOW GLEN SENIOR LIVINGFACILITY NUMBER:
435202725
ADMINISTRATOR:PAMELA D. PERALTAFACILITY TYPE:
740
ADDRESS:2991 FAIRCLIFF CTTELEPHONE:
(408) 914-1147
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:6CENSUS: 6DATE:
07/19/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Irish LadwigTIME COMPLETED:
02:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to initially open a complaint investigation. During the complaint investigation, a case management deficiencies visit was conducted due a violation observed. LPA met with Licensee, Irish Ladwig.

Upon arrival, LPA was greeted at the front door by staff (S1). Based on record review, S1 was not associated to the facility roster. Licensee and S2 states S1 started orientation and is not directly working with residents. It was stated S1 was only shadowing S2 to observe the job duties and responsibilities of a caregiver. Licensee states S1 started orientation today, 07/19/2023. Licensee states to have sent S1 for live scan but has not received S1’s background clearance. Based on review of Guardian, S1's background was "eligible - cleared" as of 07/15/2023.

Licensee voluntarily asked S1 to leave the facility.

A deficiency is being cited per California Code of Regulations, Title 22. See LIC809-D. A civil penalty is being assessed for the amount of $100 ($100 per day x 1 day = $100) for staff (S1) working at the facility without clearance transfer. Please LIC421BG.

This report was reviewed with Licensee, Irish Ladwig and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2023
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 07/19/2023 02:30 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: WILLOW GLEN SENIOR LIVING
FACILITY NUMBER: 435202725

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/20/2023
Section Cited
CCR
87355(e)(2)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) ... This requirement is not met as evidenced by:
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Licensee will associate S1 to the facility prior to S1 starting work at the facility.
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Based on record review, interview and observation the licensee did not ensure staff (S1) was associated to the facility prior to working in the facility which poses an immediate health, safety, and personal rights risk to persons in care.
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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.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2023
LIC809 (FAS) - (06/04)
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