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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202759
Report Date: 06/29/2022
Date Signed: 06/30/2022 08:27:05 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/30/2022 08:27 AM - 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: 46DATE:
06/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Aidah TayagTIME COMPLETED:
03:17 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an annual inspection today and met with Executive Director (ED) Aidah Tayag. Upon arrival, the front desk staff conducted an infection control/prevention screening, and took LPA body temperature check, then logged LPA in visitor logs.

LPA toured the facility with ED. LPA inspected main entrance, lobby area, the dinning room and activity rooms. Laundry room and kitchen were observed and inspected. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. PPE supplies were observed sufficient. LPA inspected the resident rooms, beds were observed 6 feet apart. Hand sanitizers were observed at many places in facility. Trash cans in common areas were observed with covers. The public restrooms were inspected, and trash cans were observed with covers. Posters of washing hands for 20 seconds were not observed in some public restrooms. Fire extinguishers were observed serviced on 5/3/2022. Room temperature was observed at 70 degree F. ED put the posters of washing hands for 20 seconds in public restrooms before LPA left facility.

ED stated all the staff are fully vaccinated and all the residents are fully vaccinated except two residents.

LPA discussed infection control plan with ED. ED stated ED will email the infection control plan to LPA..

No citation was issued for today's inspection. An exit interview was conducted with ED. This report was provided to ED to review and to sign.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2022
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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