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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202820
Report Date: 09/14/2021
Date Signed: 09/14/2021 04:58:32 PM

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:WHITE OAKS SENIOR LIVINGFACILITY NUMBER:
435202820
ADMINISTRATOR:LADWIG, IRISHFACILITY TYPE:
740
ADDRESS:1680 WHITE OAKS RD.TELEPHONE:
(408) 821-2630
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:6CENSUS: 4DATE:
09/14/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:56 PM
MET WITH:Justin & Irish LadwigTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Ryker Heberle conducted an unannounced pre-licensing inspection today. LPA met with Administrators (ADMs) Irish & Justin Ladwig. At around 2:01pm, LPA toured the facility inside and out. Including living room, dining room, kitchen, family room, 5 bedrooms, 3 bathrooms, utility/laundry room, and garage. A screening station was observed by the entry door for anyone coming in the facility. Facility staff properly screened LPA before entering the facility.

The facility is equipped with connected smoke detectors. The smoke detector located in the dining room was tested and observed working. All fire/carbon monoxide detectors observed to be connected. Fire extinguisher was observed in the dining room and had been last serviced in August of 2021. The kitchen, dining, living room, and family room were observed in good repair. Resident and personnel files observed to contain all necessary documentation, including Appraisal Needs and Services Plans, Physician's Reports, first aid certifications, and criminal background clearances.

Resident bedrooms were observed in good repair, furnished, with clean linens and adequate lighting. Screen door in bedroom #5 noted to be damaged. LPA advised ADMs to fix screen door. Bathrooms were observed clean and equipped with grab bars and non-skid mats. The water temperature was measured at 116 degrees F in facility bathroom. Centrally stored medication cabinet was observed. 2 days supply of perishable and 1 weeks supply of nonperishable food observed. A complete first aid kit was inspected. All outdoor and indoor passageways were observed clear and free of obstruction. No bodies of water observed.

Component III orientation was waived due to licensee's prior experience. Based on today's inspection, the physical plant is recommended for licensure pending the completion of all application documents with the Central Applications Bureau (CAB). Exit interview conducted with and copy of report provided to Administrator Irish & Justin Ladwig.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
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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