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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202875
Report Date: 09/12/2024
Date Signed: 09/12/2024 05:05:17 PM


Document Has Been Signed on 09/12/2024 05:05 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
CENTRAL COAST CR/RES, 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: 6DATE:
09/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Irish LadwigTIME COMPLETED:
04:51 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit and met with Administrator (ADM) Irish Ladwig. LPA observed 4 staff and 6 residents in the facility.

LPA checked 3 resident files and 3 staff files.

License, personal rights posters, and Administrator Certificate were observed at the main entrance. LPA toured the facility inside and out with ADM. LPA inspected living room, kitchen, dining area, restrooms, laundry room and garage. The facility has 6 resident rooms, 3 restrooms, 2 staff rooms. A storage room was observed in the garage. 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 72 degree F, and hot water temperature was observed at 119 degree F. Refrigerator temperature was measured at 40 degree F, freezer temperature was measured at 0 degree F. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. 3 half rail beds were observed in the facility, ADM provided the document for that. LPA tested resident's call button and the staff came within 1 minute.

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 8/19/2024. LPA inspected the backyard, there was no obstruction to block the walkway.

First aid box, Flash lights and night lights were observed in the facility. The last time the facility conducted fire drill was on 8/15/2024. Door alarms are installed at the main door and the door to the back yard.

No deficiency noted today. Exit interview was conducted with ADM. The report was provided to ADM for signature. A copy of the reports were provided to ADM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024
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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