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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202822
Report Date: 08/11/2022
Date Signed: 08/11/2022 11:37:46 AM


Document Has Been Signed on 08/11/2022 11:37 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: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:
08/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:31 AM
MET WITH:Janet NowickiTIME COMPLETED:
11:40 AM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 08/11/2022 at 10:31am. LPA met with facility staff member Janet Nowicki (S1). Administrator Justin Ladwig (Admin) was currently out of state and could not attend the inspection. Admin gave S1 permission to sign the report in his stead.

LPA toured the facility, including living room, kitchen, dining room, laundry room, 5 resident bedrooms, 2 staff bedrooms, 2 bathrooms, garage, and back yard. All staff members observed to be wearing masks upon LPA arrival. S1 confirmed that all staff and residents have been vaccinated.

No prohibited items noted in resident rooms. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Hand sanitizers, soap, and paper supplies were observed to be available. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. Fire extinguisher observed to be last inspected in March 2022. All cleaning supplies and chemicals noted to be in locked cabinets and closets. Smoke/carbon monoxide detectors were tested and observed to be operational.

Facility observed to have designated entry point. Staff took LPAs' temperature and screened for symptoms. 30 days supply of PPE was observed. Hand washing signs were observed in facility bathrooms. Water temperature observed to be 111.4 *F in facility bathroom. Social distancing signs observed to be posted in all public areas. Facility temperature noted to be 75* F.

No deficiencies cited during today's visit. This report was reviewed with facility staff member Janet Nowicki. Signed report was emailed to administator due to printer error.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022
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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