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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202874
Report Date: 05/24/2023
Date Signed: 05/24/2023 04:51:29 PM


Document Has Been Signed on 05/24/2023 04:51 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:MORNINGSTAR MEMORY CARE AT SAN TOMASFACILITY NUMBER:
435202874
ADMINISTRATOR:LOPEZ, IGNACIOFACILITY TYPE:
740
ADDRESS:3930 WILLIAMS RDTELEPHONE:
(669) 201-2015
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY:82CENSUS: 0DATE:
05/24/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Ignacio LopezTIME COMPLETED:
12:00 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 an unannounced pre-licensing inspection visit, and met with Administrator (ADM) Ignacio Lopez and Regional VP of Operation (VP) Phil Altman.

LPA toured the facility inside and out with ADM and VP. The facility has two stories. The facility has 51 apartments/bedrooms with capacity 82. No residents were observed to have moved in to the premises currently. Bedrooms, Med room, offices, activity rooms, dinning rooms, break room, fit room, laundry room, patio and kitchen were inspected.

First Aid Kits was observed in the facility. Non-skid mats and Bars were observed in restrooms. window screens were observed good in the bedrooms. Bedrooms, hallway and common area had functioning light fixtures. Room temperature was at 71 degree F, and hot water temperature was at 118 degree F in facility. Fire extinguisher was serviced on 4/7/2023.

The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Fire alarm and Smoke detectors were tested by ADM, and were working fine. Fire alarm exit route to parking lot were observed no obstruction to block the walkways. The elevator was functioning in the facility. Medication room, detergent room and knives storage were observed locked.

Infection Control Plan was reviewed with ADM. Component III was conducted with ADM and VP.

Exit interview was conducted with ADM and VP. The report was provided to ADM for signature. A copy of the 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: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2023
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