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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202821
Report Date: 09/29/2023
Date Signed: 09/29/2023 01:42:40 PM


Document Has Been Signed on 09/29/2023 01:42 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:
09/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Licensee IrishTIME COMPLETED:
01:45 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 Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Licensee Irish Ladwig. LPA explained the purpose of the visit.

LPA toured the facility inside out which included; the living room, kitchen, dinning room, 3 restrooms and 4 residents bedrooms. Front yard and backyard were inspected. LPA observed the backyard pool locked an inaccessible to residents in care. There was no obstruction to block the walkways.

Two day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication cabinet, knives storage cabinet, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 72 degrees F, and hot water temperature was measured in the 3 facility bathrooms to range from 106 degrees to 108 degrees in the facility bathrooms.

LPA observed two Fire extinguishers, that were on serviced on 03/08/2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by licensee, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on 09/22/2023.

LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 3 staff (S1 to S3) and 3 residents (R1-R3).

No deficiencies cited during today's visit. This report was reviewed with Licensee Irish Ladwig and a copy of the signed report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2023
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