435202738-10-27-2024-26-AS-MPAA-DAFVPQ-20241027163706

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202738
Report Date: 10/27/2024
Date Signed: 10/27/2024 04:37:35 PM

Document Has Been Signed on 10/27/2024 04:37 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:	GARDENS SENIOR LIVING		FACILITY NUMBER:	435202738
ADMINISTRATOR/ DIRECTOR:	ARELLANO, ROSARIO		FACILITY TYPE:	740
ADDRESS:	6162 VALLEY GLEN DRIVE		TELEPHONE:	(408) 807-5846
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	10/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:00 PM
MET WITH:	Daniel John Francisco - Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Maria (Mita) Partoza a conducted an unannounced required 1 year inspection visit and met with administrator Daniel John Francisco and stated the purpose of the visit. The facility is licensed to serve adults 60 and over. 1 may be bedridden and hospice waiver for 6. 3 Out of 5 are under hospice care. 5 Out of 5 are non-ambulatory, 4 out of 5 have neurocognitive disorder. LPA observed 5 residents and 4 staff were present at the facility at time of the visit. At 2:15 p.m. LPA toured the facility inside and outside with staff 1 (S1) including but not limited to the kitchen, bathroom, dining room, living room, 5 residents rooms, garage, backyard and exterior walkways. The temperature inside the home was at 72 degrees Fahrenheit. The kitchen was observed to be sanitary and organized, knives and sharps were locked and not accessible to residents. LPA observed 2 days of perishable food and 7 days of non-perishable food. Under the sink cabinet is used to store cleaning supplies and locked and not accessible to residents. The kitchen water temperature measured at 111.7 degrees Fahrenheit. The facility is maintained, sanitary and organized. The bathroom/s are equipped with grab bars, non-skid mats. The water temperature in the bathroom measured at 112.8 degree Fahrenheit. Resident's room (R1 to R5) have sufficient storage. LPA observed that medications are kept locked and inaccessible to residents. The first aid kit is complete and is accessible to staff. page 1 of 2 see LIC 809C

Romeo Manzano	TELEPHONE: (650) 388-2297
Maria Partoza	TELEPHONE: (669) 308-3994
	DATE: 10/27/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2024

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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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: GARDENS SENIOR LIVING	FACILITY NUMBER: 435202738
	VISIT DATE: 10/27/2024

NARRATIVE

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The backyard, walkways, ramps and patio are free from debris and obstruction. The facility screen windows were observed to be in good repair. The washer and dryer located in the garage are in good working condition. Laundry soap and cleaning supplies are locked and not accessible to residents in care.

The facility is equipped with a fire, smoke and carbon monoxide alert system that is in good working condition, night lights on the hallway are in good working condition. The hallway are free from obstruction.
The facility is equipped with surveillance camera in the dining, kitchen, living area, entry way, and the front exterior. ADM stated the cameras do not record, does not have audio and no data is collected. A consent form was signed by responsible parties.

LPA reviewed 3 resident records such as but not limited to the centrally stored medication and destruction record (CSMDR), admission agreement, needs and services plan, health screening and observed records to complete and updated.

LPA reviewed 3 staff records including but not limited to required training, first aid/CPR training, health screening and background clearance. All staff have criminal record clearance/fingerprints and records are complete and updated.

No deficiencies were cited during today's visit. An exit interview was provided to administrator Daniel John Francisco and a copy of the report was provided.

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end of report

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2024

LIC809 (FAS) - (06/04)

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