435202744-12-22-2020-26-AS-GKUN-BWJN62-20201222091021

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202744
Report Date: 12/21/2020
Date Signed: 12/22/2020 09:10:41 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:	WESTMONT OF MILPITAS		FACILITY NUMBER:	435202744
ADMINISTRATOR:	BRAVO, SHERYL		FACILITY TYPE:	740
ADDRESS:	80 CEDAR WAY		TELEPHONE:	(858) 729-6720
CITY:	MILPITAS	STATE: CA	ZIP CODE:	95035
CAPACITY:	225	CENSUS: 0	DATE:	12/21/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Sheryl Bravo		TIME COMPLETED:	12:30 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) Gladys Kuizon conducted a Pre-licensing tele-inspection today and met with Administrator Sheryl Bravo and Regional Director for Operations Lydia Hertzler. Due to COVID-19 restrictions, facility visits have been suspended. At 11:17 AM, LPA toured the facility with staff. Required postings were observed including COVID-19 related posters by the main entrance of the facility. On the ground floor, all common areas were inspected including the enclosed courtyard, main dining room, kitchen, fitness center, salon, activity room, theater room, offices, staff break room, and the Memory Care/Dementia unit. Facility was observed in good repair with required furnishings in residents' bedrooms. Residents' bathrooms were equipped with safety grab bars, non-skid bath flooring, and call signal systems. Running water and working toilet flushing system were observed in bathrooms. The facility has common bathrooms available. Common bathrooms were supplied with hand hygiene and paper products including toilet paper and paper towels. The kitchen is equipped with a 3-part sink, dishwasher system, refrigeration system, and freezer. Food was observed stored in a separate area from toxic, cleaning materials. Facility's swimming pool is located on the first level and is locked. Access is restricted. The 40-capacity Memory Care/Dementia unit was observed with its own dining and activity area. A kitchen/food preparation area with its own dishwasher was also available in this unit. An enclosed courtyard with delayed egress exits was inspected and observed in good repair. Continued, see LIC 809-C, page 2 of 2.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys Kuizon	TELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2020

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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: WESTMONT OF MILPITAS	FACILITY NUMBER: 435202744
	VISIT DATE: 12/21/2020

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Medications room and records room were observed with locking doors and restricted access. First aid kits were available.

Exits were observed clear and unobstructed. Delayed egress in the Memory Care Unit was installed. Combination smoke and carbon monoxide detectors were observed in all bedrooms. Motion sensor lighting were installed in hallways and common areas. Stairwells were equipped with emergency evacuation chairs on each level. Elevators were observed in good working condition.

No deficiencies were noted during inspection. Component III orientation has been waived due to Administrator's background and experience. Based on today's inspection, the physical plant is recommended for licensure pending the completion of all application documents with the Central Applications Unit (CAU).

A copy of this report was provided via email to Administrator for review and signature.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys Kuizon	TELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2020

LIC809 (FAS) - (06/04)

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