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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202738
Report Date: 08/15/2022
Date Signed: 08/23/2022 09:01:53 AM


Document Has Been Signed on 08/23/2022 09:01 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:GARDENS SENIOR LIVINGFACILITY NUMBER:
435202738
ADMINISTRATOR:ARELLANO, ROSARIOFACILITY TYPE:
740
ADDRESS:6162 VALLEY GLEN DRIVETELEPHONE:
(408) 807-5846
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:6CENSUS: 6DATE:
08/15/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:ARELLANO, ROSARIOTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Christine Dolores conducted a scheduled technical assistance visit and met with Administrator, Rosario Arellano.

During visit, LPA conducted a Zoom tour of the facility with Program Clinical Consultant (PCC), Anna Guinto and Licensing Program Manager (LPM), Sarah Yip. The purpose of the visit was to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility.

During today's tele-visit, the following recommendations were made to the facility:

1. Provide staff with N95 fit-testing
2. Conduct N95 seal check while working on getting staff N95 fit-tested
3. Screen COVID positive resident's symptoms at least twice daily (AM/PM) and as often as needed
4. If the COVID negative residents want to be in the common areas, encourage social distancing

No deficiencies were cited per California Code of Regulations, Title 22.

This report was reviewed via telephone with Administrator, Rosario Arellano and a copy of the report was emailed for signature.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2022
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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