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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202759
Report Date: 03/30/2022
Date Signed: 03/30/2022 04:50:58 PM


Document Has Been Signed on 03/30/2022 04:50 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:WESTGATE VILLAFACILITY NUMBER:
435202759
ADMINISTRATOR:TAYAG, AIDAHFACILITY TYPE:
740
ADDRESS:5425 MAYME AVENUETELEPHONE:
(408) 366-6510
CITY:SAN JOSESTATE: CAZIP CODE:
95129
CAPACITY:60CENSUS: 48DATE:
03/30/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Aidah TayagTIME COMPLETED:
04:08 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management for the exception request for the prohibited health condition of the resident, and met with administrator (ADM) Aidah Tayag.

LPA visited R1 and the bedroom with ADM. Upon arrival at R1's room, R1 was sleeping. ADM woke R1 up, R1 seemed comfortable. LPA talked to R1, but R1 did not answer any question. ADM stated R1 can hear but cannot talk. R1 cannot get up from bed by R1 self. LPA saw R1 was wearing oxygen. ADM stated R1 wears oxygen 24 hours/7 days. LPA observed R1 was awake, but cannot communicate with LPA.

ADM stated R1 needs help to transfer from bed to wheelchair. ADM stated R1 cannot use walker. ADM stated the facility takes care R1 for incontinence care every two hours. ADM stated the staff take R1 to dinning room and feed R1 for breakfast, lunch and dinner. ADM stated R1 takes nap 2:00PM to 4:00PM every day. ADM stated the facility helps R1 for dressing and grooming. ADM stated facility helps R1 for toileting and showering. Facility helps R1 taking showers two times per week. ADM stated the facility helps R1 for the medication. ADM stated R1 has nurse practitioner visiting at facility weekly.

ADM stated R1 stayed at facility for 8 years, and R1's family members want R1 to stay at facility. R1 Functional Capability assessment, Preplacement appraisal. Appraisal Needs and Service Plan, document from hospice care, Letter from family and Physician report were obtained.

Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022
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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