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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202725
Report Date: 07/05/2024
Date Signed: 07/05/2024 02:30:40 PM


Document Has Been Signed on 07/05/2024 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:
07/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:12 PM
MET WITH:Licensee Irish LadwigTIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Licensee (LN) Irish Ladwig. During the visit, LPA observed 5 residents and 3 staff.

LPA toured the facility inside out with LN which included the Living room, kitchen, dining room, 2 restrooms and 6 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 79 degrees F, and hot water temperature was measured at 119 degrees F in both resident bathrooms.

Fire extinguisher was serviced in March 7, 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by LN, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on April 18, 2024.

LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 2 staff and 2 residents.

No deficiencies cited during today's visit. This report was reviewed with Licensee Irish Ladwig and a copy of the signed report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2024
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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