<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202820
Report Date: 09/06/2024
Date Signed: 09/16/2024 03:55:04 PM


Document Has Been Signed on 09/16/2024 03:55 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:
09/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Irish LadwigTIME COMPLETED:
11:06 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Marcella Tarin and David Marrufo conducted an unannounced required 1 year annual inspection. LPAs met with Administrator Irish Ladwig. LPAs toured the facility inside and out.

LPAs toured the kitchen. LPAs observed a supply of 7 days of nonperishable food and 2 days of perishable food. LPAs observed the refrigerator temperature at 30 degrees F and freezer temperature at 0 degrees F. LPAs observed sharps locked in a drawer. LPAs toured 2 out of 2 hallway resident bathrooms. The water temperature in resident bathrooms were recorded at 118 degrees F and 110 degrees F. All bathrooms had soap, paper towels and functioning lights. LPAs observed the smoke detectors to be functioning properly. LPAs observed service tags on the fire extinguisher with a service date of 3/8/2024.

LPAs toured 4 out of 4 resident rooms. 4 out of 4 resident rooms had functioning lights, and storage space for resident belongings.

LPAs reviewed 6 Centrally Stored Medication and Destruction Records and found to be complete. 6 out of 6 resident records were reviewed and found to be complete. LPAs reviewed 4 staff records. 4 out 4 reviewed staff records were complete. 4 out 4 staff members obtained background and fingerprint clearance.

LPAs observed a fire drill log, last fire drill recorded 7/22/2024.

LPAs toured the outside of the facility. LPAs observed one section of the floor of the back patio to be fragile and became depressed when LPAs stepped on it. An Advisory Note was issue. See LIC9102 for more information.

No deficiencies were cited as per California Code of Regulations Title 22. This report was reviewed with Administrator Irish Ladwig. A copy of this report was provided.
SUPERVISOR'S NAME: Jin JackieTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella TarinTELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024
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 1