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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202759
Report Date: 06/30/2023
Date Signed: 06/30/2023 05:01:09 PM


Document Has Been Signed on 06/30/2023 05:01 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: 41DATE:
06/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Aidah TayagTIME COMPLETED:
04:23 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.

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. Visitors visiting hours posters were observed at the main entrance. Facility license, Administrator Certificate, and Personal Rights posters were observed at the main entrance.

Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Fire extinguishers were observed serviced on 6/5/2023. 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 72 degree F. Hot water temperature was observed at 105 degree F.

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: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2023
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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