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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202738
Report Date: 10/25/2022
Date Signed: 10/25/2022 04:28:16 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/25/2022 04:28 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
CCLD Regional Office, 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:
10/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:ROSARIO ARELLANOTIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) ROSARIO ARELLANO. Upon arrival, Staff Pauline Acorda (S1) took LPA body temperature, and checked LPA in the visitor log book.

LPA toured the facility inside and out with ADM. COVID posters were observed at main entrance and the facility. Screening station with masks, hand sanitizer, thermometer and visitor log book was observed at the main entrance. Living room, kitchen, dinning room and two restrooms were inspected. Trash cans were observed with covers. Paper towels were observed with holders. Posters of washing hands were observed by the sinks in kitchen and restrooms, but poster of washing hands for 20 seconds was not observed in kitchen. ADM stated ADM will put the posters of washing hands for 20 seconds at kitchen today. Six single resident bedrooms, and laundry room were inspected. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. PPE supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 70 degree F, and hot water temperature was at 106 degree F in facility. Six residents and 3 staff were observed in facility.

Fire extinguisher was serviced on 12/1/2021. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

ADM stated all the residents and staff are fully vaccinated. ADM stated the facility already submitted the Infection Control Plan to CCL office. No citation were noted today. Exit interview was conducted with ADM. This report was provided to ADM
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022
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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