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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202821
Report Date: 03/15/2023
Date Signed: 03/15/2023 12:31:01 PM


Document Has Been Signed on 03/15/2023 12:31 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:WILLOW OAKS SENIOR LIVINGFACILITY NUMBER:
435202821
ADMINISTRATOR:AGNES TEODOROFACILITY TYPE:
740
ADDRESS:1573 WILLOW OAKS DR.TELEPHONE:
(408) 914-1147
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:6CENSUS: 5DATE:
03/15/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:14 AM
MET WITH:Justin and Irish LadwigTIME COMPLETED:
12:45 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 Analysts (LPAs) David Marrufo and Manuel Monter conducted a Case Management visit as part of a complaint investigation and met with Co-Licensees Justin and Irish Ladwig.

During visit, LPAs interviewed staff S1 and Co-Licensees. During interview, S1 stated that resident R1 had a fall, but S1 did not submit an Unusual Incident Report to the Department because the staff did not need to call 911 for the resident due to not observing any injury on resident during assessment.

A Technical Advisory was issued. See LIC9102 for more information.

This report was reviewed with Co-Licensees Justin and Irish Ladwig and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2023
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