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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202744
Report Date: 12/29/2022
Date Signed: 12/29/2022 05:03:28 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/29/2022 05:03 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:WESTMONT OF MILPITASFACILITY NUMBER:
435202744
ADMINISTRATOR:BRAVO, SHERYLFACILITY TYPE:
740
ADDRESS:80 CEDAR WAYTELEPHONE:
(408) 770-9575
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY:225CENSUS: 100DATE:
12/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Lauren Powell, EDTIME COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Annual Inspection visit today, and met with Administrator(ADM) Lauren Powell. Upon Arrival, the facility front desk staff took LPA's body temperature, and checked LPA in the visitor log book.

LPA toured the facility inside and out with ADM. LPA observed COVID posters at the main entrance and in facility. LPA observed many hand sanitizers in the facility. LPA toured the common areas including dining room, activity room, theater room, hallways, kitchen, laundry room, fitting room, public restrooms, library, bistro area, and offices. LPA toured the resident rooms in Assistant Living Unit, and Memory Care Unit. The beds in shared rooms were observed 6 feet apart. The posters of washing hands for 20 seconds were not observed by the sinks in the public restrooms. ADM stated the facility will put the posters of washing hands for 20 seconds by the sinks in common area within 7 days. The swimming pool room was observed locked.

Medication rooms were observed locked. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. PPE supplies were observed sufficient. Cleaning product rooms were observed locked. Room temperature was at 72 degree F, and hot water temperature was at 110 degree F in facility. Fire extinguishers were serviced on 8/23/2022. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors.

LPA toured the courtyard, nothing was observed abnormal. ADM stated all the residents and staff are fully vaccinated and done with booster. The facility already submitted the Infection Control Plan to CCL office.

No citation was noted today. Exit interview was conducted with ADM. A copy of 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: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2022
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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