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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202821
Report Date: 09/30/2022
Date Signed: 09/30/2022 10:51:52 AM


Document Has Been Signed on 09/30/2022 10:51 AM - 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: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: 4DATE:
09/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Irish Ladwig and Justin LadwigTIME COMPLETED:
10:40 AM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection focusing on infection control. LPA met with Licensees, Irish Ladwig and Justin Ladwig.

LPA toured the facility with staff to include the kitchen, living room, bedrooms, bathroom, laundry room, and exterior. All fire exit routes are clear and free of obstruction. Swimming pool observed fenced and locked. All staff observed to be wearing a face mask.

Facility has a designated symptom screening and temperature check area for all visitors and staff. Hand sanitizer available at entry. LPA observed resident's daily symptom and temperature check log. Bathrooms supplied with paper products, hygiene products, hand washing sign, and lidded trash can. LPA observed the facility's Personal Protective Equipment (PPE) supplies. Staff are N95 fit tested. Facility has procedures to isolation and infection control training. Facility staff clean and disinfect multiple times daily and as needed. The following posters observed to include cough etiquette, symptoms of COVID, required mask, feeling ill, and visitor policy.

During visit, LPA obtained the change of Administrator documents; letter and qualifications, LIC9182, LIC508, and administrator certificate.

No deficiencies were cited per California Code of Regulations, Title 22. Advisory note provided.

This report was reviewed with Licensees Irish Ladwig and Justin Ladwig and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2022
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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