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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202822
Report Date: 01/31/2022
Date Signed: 01/31/2022 01:37:18 PM

Document Has Been Signed on 01/31/2022 01:37 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:HILLSDALE SENIOR LIVINGFACILITY NUMBER:
435202822
ADMINISTRATOR:LADWIG, JUSTINFACILITY TYPE:
740
ADDRESS:1538 HILLSDALE AVE.TELEPHONE:
(408) 914-1147
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY: 6CENSUS: 6DATE:
01/31/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Irish LadwigTIME COMPLETED:
10:50 AM
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Licensing Program Analyst (LPA) Christine Dolores conducted a scheduled technical assistance visit and met with Licensee, Irish Ladwig. During visit, LPA conducted a Facetime tour of the facility with Program Clinical Coordinator (PCC) Roxane Fangon and Licensing Program Manager (LPM) Romeo Manzano. The purpose of the visit was to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility.

The licensee reports 4 staff have been cleared to return to work and 2 residents have been cleared for isolation.

During today's tele-visit, the following recommendations were made to the facility by PCC:

1. Include the question of COVID-19 exposure on the staff daily screening log.
2. Disinfect and sanitize all rooms after isolation period. Aerate the facility for a minimum of 1 hour, if weather permits.
3. Place a paper towel dispenser in the common bathroom.
4. Remove all use of cloth towels in the kitchen area.

No deficiencies were cited as per California Code of Regulations, Title 22. This report was reviewed via telephone with licensee Irish Ladwig and a copy of the report was emailed for signature.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2022
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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