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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202875
Report Date: 09/09/2022
Date Signed: 09/09/2022 04:02:37 PM


Document Has Been Signed on 09/09/2022 04:02 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:LOS GATOS SENIOR LIVINGFACILITY NUMBER:
435202875
ADMINISTRATOR:LADWIG, IRISHFACILITY TYPE:
740
ADDRESS:1732 MYRA DRTELEPHONE:
(408) 914-1147
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:6CENSUS: 0DATE:
09/09/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Irish LadwigTIME COMPLETED:
10:11 AM
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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.

LPA toured the facility inside out with ADM. LPA inspected living room, kitchen, dinning area, 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. 2 bathrooms were inspected. Non-skid mats and handle bars were observed in bathrooms. Room temperature was observed at 74 degree F, and hot water temperature was observed at 110 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 3/31/2022. LPA inspected the backyard, there was no obstruction to block the walkway.

LPA discussed Infection Control Plan with ADM. ADM stated ADM will send it to LPA. 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: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2022
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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