435202875-9-29-2023-26-AS-CCHG-CW5NWC-20230929104918

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202875
Report Date: 09/28/2023
Date Signed: 09/29/2023 10:49:25 AM

Document Has Been Signed on 09/29/2023 10:49 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME:	LOS GATOS SENIOR LIVING		FACILITY NUMBER:	435202875
ADMINISTRATOR:	LADWIG, IRISH		FACILITY TYPE:	740
ADDRESS:	1732 MYRA DR		TELEPHONE:	(408) 914-1147
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95124
CAPACITY:	6	CENSUS: 6	DATE:	09/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Irish Ladwig		TIME COMPLETED:	04:36 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 annual inspection visit and met with Administrator (ADM) Irish Ladwig. LPA checked 5 resident files and 4 staff files. License, personal rights, Administrator Certificate and visitor hours posters were observed at the main entrance. LPA toured the facility inside out with ADM. LPA inspected living room, kitchen, dinning area, restrooms, laundry room and garage. The facility has 6 resident rooms, 3 restrooms, 2 staff rooms. A room was observed in the garage. ADM stated that is a storage room. Medication closet, knives closet, and cleaning product closet were observed locked. Non-skid mats and handle bars were observed in bathrooms. Room temperature was observed at 76 degree F, and hot water temperature was observed at 110 degree F. Refrigerator temperature was measured at 35 degree F, freezer temperature was measured at -10 degree F. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. The facility is equipped with fire alarm and smoke and carbon monoxide detectors. ADM tested the smoke and carbon monoxide detectors, and they were working fine. The fire extinguishers were observed on service on 8/15/2023. LPA inspected the backyard, there was no obstruction to block the walkway. LPA discussed Infection Control Plan with ADM. ADM stated ADM will update it and send to LPA. A deficiency was noted today. LIC809-D was attached. Exit interview was conducted with ADM. The re[ort was provided to ADM for signature. A copy of the reports were provided to ADM.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

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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Document Has Been Signed on 09/29/2023 10:49 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 LIVING	FACILITY NUMBER: 435202875
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(c)

All window screens shall be claen and maintained in good repair. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as the screen of one of the resident bedroom was not in a good repair which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/05/2023
	Plan of Correction
1 2 3 4	ADM agreed to submit a plan of correction by the POC due date to fix the problem of the screen of the bedroom window.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC809 (FAS) - (06/04)

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