435202820-9-22-2025-26-AS-MPAA-DLRVFR-20250922162423

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202820
Report Date: 09/22/2025
Date Signed: 09/22/2025 04:24:40 PM

Document Has Been Signed on 09/22/2025 04:24 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 LIVING		FACILITY NUMBER:	435202820
ADMINISTRATOR/ DIRECTOR:	LADWIG, IRISH		FACILITY TYPE:	740
ADDRESS:	1680 WHITE OAKS RD.		TELEPHONE:	(408) 821-2630
CITY:	CAMPBELL	STATE: CA	ZIP CODE:	95008
CAPACITY: 6		CENSUS: 6	DATE:	09/22/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:02 PM
MET WITH:	James Equing - Designated Administrator		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

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 Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced required 1-year inspection visit, met with designated administrator (DADM) Azarel James Equing and Licensee (LIC) Irish Ladwig who arrived at 2:10 p.m. The facility is licensed to serve adults 60 and over 6 ambulatory, 3 may be non-ambulatory, and 2 may be bedridden and hospice waiver for 3. At 1:10 p.m. LPA was accompanied by DADM during inspection of the facility's interior and exterior area. LPA inspected the kitchen, dining, living room 5 resident bedroom, laundry area and back deck patio. LPA observed that the deck and ramp addressed from prior annual visit was addressed and repaired. LPA observed that the exterior and interior walkways are free from obstructions. LPA inspected 5 residents rooms and observed rooms have sufficient storage to store residents personal belongings. The bathrooms are equipped with the grab bars, and anti skid mats. 1 Out of 5 resident room is shared, and 4 out of 5 bedroom are single occupancy. Emergency exit are free from obstruction and debris. Knives, sharps and medications are locked and not easily accessible to residents in care. Chemicals, cleaning supplies and laundry products are locked and not accessible to residents in care. The facility is equipped with audible alarms. See LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/22/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2025

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 3

California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

Page: 2 of 3

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: WHITE OAKS SENIOR LIVING	FACILITY NUMBER: 435202820
	VISIT DATE: 09/22/2025

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
26
27
28
29
30
31
32

The facility temperature is at 74 degree F, the refrigerator temperature is at 32 degree F, freezer temperature is at 0 degree F, hot water temperature in the resident bathroom and kitchen measured at 105 degree F.

LPA observed food supply for 2 days of perishable and 7 days of non-perishable food items.

The facility is equipped with smoke and carbon monoxide alarm system, a fire extinguisher that was last inspected on 03/11/2025. LPA verified the first aid kit is complete with instruction manual.

LPA reviewed the facility file and able to verify quarterly fire and earthquake drill preparedness training. The training was administered on the following dates 01/19/25, 04/16/25 and 07/02/25.

LPA reviewed 4 resident records including but not limited to the Centrally Stored Medication Record (CSMDR), physician's report, appraisal needs and services plan. LPA reviewed 4 staff record including but not limited to background clearance, certificates, and training. Resident and staff records are complete and up to date. LPA requested copies of updated LIC 500, LIC 308, dementia care plan and liability insurance.

No deficiencies were cited during today's visit based on California Code of Regulation (CCR) Title 22. An exit interview was conducted with Designated Administrator (DADM) Azarel James Equing and Licensee (LIC) Irish Ladwig. A copy of the report was provided.

End of Report

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/22/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2025

LIC809 (FAS) - (06/04)

Page: 3 of 3