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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202744
Report Date: 12/20/2021
Date Signed: 12/20/2021 02:58:16 PM

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 MILPITASFACILITY NUMBER:
435202744
ADMINISTRATOR:BRAVO, SHERYLFACILITY TYPE:
740
ADDRESS:80 CEDAR WAYTELEPHONE:
(408) 770-9575
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY:225CENSUS: 48DATE:
12/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Lydia HertzlerTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Christine Dolores conducted an unannounced annual required inspection to focus on infection control. LPA met with Cristina Pedaghat, Business Office Director, Conrado Duarte, Community Relations Director, and Lydia Hertzler, Regional Director.

During today's visit, LPA toured the facility inside and outside to include the lobby, bistro, dining rooms, entertainment center, fitness center, assisted living, memory care, team member lounge, and courtyard. Fire exits were free and clear of obstruction.

LPA observed a central entry point, screening area, and hand sanitizer for all residents, visitors and staff. LPA observed the following posters to include: cover your cough, hand washing, and prevent the spread of COVID-19. Restrooms have paper supplies and soap available for staff, residents, and visitors. LPA observed facility to have a sufficient amount of PPE supplies. Facility disinfect and sanitize high touch surfaces multiple times daily and as needed. Facility has a designated visitation area. Majority of staff are N95 fit tested.

LPA reviewed the facility policies and procedures to include screening, visitation, isolation, disinfecting, training, and social distancing.

LPA advised facility to encourage social distancing by posting signs and/or stickers throughout all common areas.

No deficiencies cited during today's visit per California Code of Regulations, Title 22.

This report was reviewed with Lydia Hertzler and a copy of this report was provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021
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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