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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202783
Report Date: 09/22/2022
Date Signed: 09/22/2022 03:39:18 PM


Document Has Been Signed on 09/22/2022 03:39 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:CAMDEN SENIOR LIVINGFACILITY NUMBER:
435202783
ADMINISTRATOR:LADWIG, IRISHFACILITY TYPE:
740
ADDRESS:1607 INGLIS LANETELEPHONE:
(408) 677-3111
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY:6CENSUS: 6DATE:
09/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:John Evangelista and Irish LadwigTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Christine Dolores and Simi Rai arrived unannounced to conduct the facility's annual visit focusing on infection control. LPAs met with Administrator, John Evangelista and Licensee, Irish Ladwig.

During visit, LPAs toured the facility to include the living room, dining room, resident rooms, bathrooms, kitchen, garage, and backyard, All fire exit routes were free and clear of obstruction. Facility temperature maintained at 75 degrees Fahrenheit. Staff were advised to wear a face mask during work.

Facility has a designated entry point for symptom screening and temperature check for all visitors. LPA Dolores advised for staff to continue documenting their daily temperature and symptom screening prior to the start of their shift. Hand sanitizer made available at entry and throughout facility. Bathrooms supplied with hand washing sign, hygiene products, and paper supplies. LPAs observed facility's Personal Protective Equipment (PPE) supplies. Staff are N95 fit-tested. Facility has procedures to isolation, testing, and visitation. Staff are trained on infection control. Facility staff clean and disinfect multiple times daily and as needed. The following posters observed to include symptoms of COVID-19, required mask, social distancing, and visitation procedures.

At 01:31pm, LPAs observed multiple canned goods that were expired. At 01:33pm, LPAs observed multiple condiments and dairy products in the refrigerator that were expired. Administrator immediately removed and discarded the items.

A deficiency was cited per California Code of Regulations, Title 22. Advisory notes provided. This report was reviewed with John Evangelista and Irish Ladwig and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6


Document Has Been Signed on 09/22/2022 03:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: CAMDEN SENIOR LIVING
FACILITY NUMBER: 435202783

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the facility did not discard expired canned foods, condiments, and dairy products from the pantry and refrigerator which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2022
Plan of Correction
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Licensee will go through all food supply and discard items that are expired or damaged. Licensee will send a plan of action to ensure items in the food supply are not expired or damaged to LPA Dolores by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022
LIC809 (FAS) - (06/04)
Page: 6 of 6