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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202854
Report Date: 01/04/2022
Date Signed: 01/04/2022 01:06:16 PM

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:CAMBRIAN SENIOR LIVINGFACILITY NUMBER:
435202854
ADMINISTRATOR:LADWIG, JUSTINFACILITY TYPE:
740
ADDRESS:3520 MAY LANETELEPHONE:
(408) 914-1147
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:6CENSUS: DATE:
01/04/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Justin Ladwig, ADMTIME COMPLETED:
12:05 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) Steve Chang conducted a pre licensing inspection visit, and met with administrator (ADM) Justin Ladwig. Upon arrival, ADM took LPA body temperature and checked LPA into the guest book. Screening station with thermometer, masks, hand sanitizer was observed at the main entrance. COVID posters were observed at the main entrance and in facility. ADM's wife Irish Ladwig (IL) was observed in facility.

LPA toured the facility inside out with ADM. LPA inspected family room, kitchen, dinning area, 2 reading rooms, and laundry room. Medication closet, knives closet, and cleaning product closet were observed locked. There are 6 single rooms for residents, and one staff live-in room in facility. 3 bathrooms were inspected. ADM stated the facility will put non-skid mats in bathrooms. Not all paper towels were with holders, ADM stated the facility will fix this issue in two days. Room temperature was observed at 70 degree F, and hot water temperature was observed at 112 degree F.

The facility is equipped with smoke and carbon monoxide detectors. The facility equipped with fire alarm. ADM tested the smoke and carbon monoxide detectors, and they were working fine. ADM tested the fire alarm, and it was working fine. The fire extinguishers were observed on service on 11/05/2021. LPA inspected the backyard, there was no obstruction to block the walkway.

LPA discussed LIC808 mitigation plan with ADM. ADM stated all staff are fully vaccinated and done with booster shots. Component III orientation was conducted with ADM.

No deficiency or issue noted during inspection. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of this report was emailed to ADM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022
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