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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202743
Report Date: 07/15/2020
Date Signed: 07/17/2020 08:52:33 AM

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:CAMPBELL SENIOR LIVINGFACILITY NUMBER:
435202743
ADMINISTRATOR:LADWIG, JUSTINFACILITY TYPE:
740
ADDRESS:426 DALLAS DRTELEPHONE:
(408) 628-4158
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:6CENSUS: 5DATE:
07/15/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Irish LadwigTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted a Case Management Tele-Visit via telephone call to Irish Ladwig Licensee. LPA informed Irish Ladwig of the purpose of the call to obtain additional information related to the Death of resident (R1) while away from the care home. Due to the COVID 19 situation, the Department is not conducting on site investigations at this time.

LPA interviewed Irish Ladwig and requested the following documents to be forwarded to Community Care Licensing for review: Incident Report, Death Report, Physician's Report, Assessment, Appraisal Needs and Services Plan, Power of Attorney, and Sign In and Sign Out Log.

Additional information may be required to complete the Case Management Investigation.

This report was reviewed with Irish Ladwig and a copy forwarded via email for review and signature purposes.
SUPERVISOR'S NAME: George NwaforTELEPHONE: (650) 269-7419
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE:
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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