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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202820
Report Date: 09/08/2022
Date Signed: 09/08/2022 03:02:37 PM


Document Has Been Signed on 09/08/2022 03:02 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: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: 6DATE:
09/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:47 PM
MET WITH:Irish LadwigTIME COMPLETED:
03:05 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 09/08/2022 at 1:47pm. LPA met with facility Administrator Irish Ladwig (Admin).

LPA toured the facility, including living room/dining room, kitchen, laundry room, 2 staff bedrooms, 5 resident bedrooms, 3 bathrooms, back yard, and garage. Staff members were not observed to be wearing masks upon LPA arrival. Admin confirmed that all staff and residents have been vaccinated.

Facility observed to have designated entry point. Staff took LPA's temperature and screened for symptoms. 30 day supply of PPE observed. Restrooms were not stoked with paper towels. Hand washing signs observed to be in all bathrooms. Social distancing signs observed to be posted in all public areas.

Facility infectious control plan has already been submitted. No prohibited items noted in resident rooms. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Hand sanitizers, soap, and paper supplies were observed to be available. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. Fire extinguishers observed to have been inspected in March of 2022. Facility carbon monoxide detector tested and observed to be in working order. Facility water temperature observed to be at 119.7 *F.

No deficiencies cited during today's visit. Advisory notes issued. This report was reviewed with Administrator Irish Ladwig and a copy of the signed report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2022
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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