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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202759
Report Date: 06/26/2024
Date Signed: 06/26/2024 04:56:22 PM


Document Has Been Signed on 06/26/2024 04:56 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: 54DATE:
06/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Aidah TayagTIME COMPLETED:
12:52 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an annual inspection today and met with Executive Director (ED) Aidah Tayag.

LPA checked 5 residents' files and 5 staff's files.

The facility has 53 residents and 20 staff in the facility.

LPA toured the facility with ED. The visiting hours poster was observed in the main entrance. License, Administrator Certificate, and Personal Rights posters were observed in the main entrance. LPA inspected main entrance, lobby area, the dinning room, restrooms, break room and activity rooms. Laundry room and kitchen were observed and inspected. Chemical storage room, medication room and medication cart were observed locked.

Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Fire extinguishers were observed serviced on 12/11/2023. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors were tested by ED, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

Room temperature was observed at 74 degree F. Hot water temperature was observed at 117 degree F. The temperature of refrigerator is 38 degree F and the temperature of the freezer is -5 degree F. Emergency light system and first aid boxes were observed in the facility. The last time the facility conducted the emergency drill was on 6/3/2024.

Exit interview was conducted with ED. This report was provided to ED for signature. A copy of the report was provided to ED.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2024
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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