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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202725
Report Date: 08/30/2022
Date Signed: 08/30/2022 01:51:43 PM


Document Has Been Signed on 08/30/2022 01:51 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:
08/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:38 PM
MET WITH:Pamela PeraltaTIME COMPLETED:
01:54 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 08/30/2022 at 12:38pm. LPA met with facility Administrator Pamela Peralta.

LPA toured the facility, including 2 living rooms, kitchen, dining room, laundry room, 6 resident bedrooms, 1 staff bedroom, 2 bathrooms, garage, and back yard. All staff members observed to be wearing masks upon LPA arrival. Admin confirmed that all staff and residents have been vaccinated.

No prohibited items noted in resident rooms. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Hand sanitizers, soap, and paper supplies were observed to be available. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. Fire extinguisher observed to be last inspected in March 2022. All cleaning supplies and chemicals noted to be in locked cabinets and closets. Smoke/carbon monoxide detectors were tested and observed to be operational.

Facility observed to have a designated entry point. Staff took LPAs' temperature and screened for symptoms. 30 days supply of PPE was observed. Hand washing signs were observed in facility bathrooms. Water temperature observed to be 105.4 *F and 116.3*F in facility bathrooms. Social distancing signs observed to be posted in all public areas. Facility temperature noted to be 75*F.

No deficiencies cited during today's visit. This report was reviewed with facility Administrator Pamela Peralta. Signed report was emailed to Administrator due to printer error.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2022
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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