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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202854
Report Date: 01/26/2023
Date Signed: 01/26/2023 04:48:23 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/26/2023 04:48 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: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: 6DATE:
01/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Irish LadwigTIME COMPLETED:
10:05 AM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection, and met with Administrator (ADM) .Irish Ladwig .

Upon Arrival, ADM took LPA's body temperature, and checked LPA in the visitor log book. LPA observed the COVID posters in the facility. Two staff and six residents were observed in facility.

LPA toured the facility with ADM inside and out. LPA inspected living room, kitchen, dinning area, 2 reading rooms, and laundry room. There are 6 single rooms for residents, and one staff live-in room in facility. 3 bathrooms were inspected. All trash cans were observed with covers. All paper towels were observed with holders. Posters of washing hands for 20 seconds were observed by the sinks in kitchen and restrooms. Two days perishable foods and seven nonperishable foods were observed sufficient. Fire extinguisher's service date was observed on 1/06/2023. Room temperature was observed at 71 degree F. Hot water was observed at 112 degree F. Medication cabinet, Knife closet, and cleaning products closet were observed locked. PPE supplies were observed sufficient. Smoke dictators were tested and were working fine.

Front yard and back yard were inspected. No obstruction was observed to block the walkway.

ADM stated all the residents and staff are fully vaccinated and done with booster shots. ADM already submitted Infection Control Plan to CCL office.

No citation was issued today. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of this report was provided to ADM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
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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