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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202821
Report Date: 08/24/2021
Date Signed: 08/25/2021 09:02:24 AM

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:WILLOW OAKS SENIOR LIVINGFACILITY NUMBER:
435202821
ADMINISTRATOR:LADWIG, JUSTINFACILITY TYPE:
740
ADDRESS:1573 WILLOW OAKS DR.TELEPHONE:
(408) 914-1147
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:6CENSUS: 5DATE:
08/24/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Justin Ladwig & Irish LadwigTIME COMPLETED:
01:45 PM
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At approximately 10:18 AM, Licensing Program Analysts (LPA) Steve Nguyen, conducted a Pre-Licensing Inspection at facility. LPA met with Licensee Justin and Irish Ladwing; explained the purpose of the visit, and conducted an inspection of facility inside and out.

Facility’s exits were observed to be free of hazards and obstructions. The facility has an Emergency Disaster Preparedness Plan in place, including Covid 19 preparedness. Smoke and carbon monoxide detectors are in working conditions. All toxins, cleaning supplies and hazardous materials were locked in both cabinet and closet space. Water temperature in bathroom was checked and it was at 110 degrees. Sharp utensils were observed locked in kitchen cabinet. Fire extinguishers located in laundry room and kitchen hallway; both extinguishers were checked on 8/1/2021 by fire marshal. Observed that facility has 3 days of perishable and 7 days Non-perishable foods on site.

Medications secured in a cabinet. First Aid kit was stocked with supplies to include but not limited to: scissors, tweezers, thermometer, and first aid manual.

At approximately 12:30 PM, review of Component III was completed.

The physical plant is approved for Licensure pending the final approval by Centralized Application Bureau (CAB). No deficiencies were cited per the California Code of Regulation Title 22.

LPA review report summary with Licensee Justin Ladwig and a copy was provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Steve NguyenTELEPHONE: (650) 676-0051
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
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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