435202895-12-8-2023-26-AS-CCHG-CYBLWZ-20231208080755

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202895
Report Date: 12/07/2023
Date Signed: 12/08/2023 08:08:13 AM

Document Has Been Signed on 12/08/2023 08:08 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:	MORNINGSTAR ASSISTED LIVING OF WEST SAN JOSE		FACILITY NUMBER:	435202895
ADMINISTRATOR:	WELCH, JOYCE		FACILITY TYPE:	740
ADDRESS:	1380 S DEANZA BLVD		TELEPHONE:	(669) 295-6500
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95129
CAPACITY:	149	CENSUS: 0	DATE:	12/07/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Joyce Welch		TIME COMPLETED:	01:00 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 Analysts (LPAs) Steve Chang and Mita Partoza conducted an unannounced pre-licensing inspection visit, and met with Administrator (ADM) Joyce Welch and Turney Munson VP of Operation. LPAs toured the facility inside and out with ADM and VP. The facility has four stories, a rooftop and under ground parking lot. The facility has 103 apartments/bedrooms with capacity of 149. No residents currently resides in the facility. LPAS inspected the following areas: resident apartment, medication, spa, enrichment, theater, fitness, activity rooms, the dinning and, laundry area. LPAs also inspected the outdoor, kitchen and memory care floor which is located on the 2nd floor. LPAs observed the delay opening for the memory floor and tested emergency buttons on the wall, and the emergency call box for 911. The memory care floor is secured in compliance with Title 22. First Aid Kits was checked and found to be in compliance. Non-skids floors and grab bars were installed in restrooms. The bedrooms has screened windows. The entire building hallways and common area had functioning light fixtures. Room temperature was at 68 degree F, and hot water temperature was at 115 degree F. Temperature of refrigerator was observed 32 degree F, and the temperature of freezer was observed 0 degree F. Food storage can hold the 2 days of perishable food and 7 days of non-perishable food for the entire building. Fire extinguisher was acquired on 3/14/23. 7/28/23 and are strategically placed in the entire building. Underground parking has ample space for visitors and staff and comply with ADA. Rooftop was observed to be secured with family area. LPAs tested the fire alarms, alarms in restroom and resident bedrooms that alerts staff on timely manner. ADM stated caregivers and managers are alerted on their work tablets. LPAs tested the emergency call box and it connected to 911 dispatcher. continued to LIC 809C page 1 of 2

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

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 2

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: MORNINGSTAR ASSISTED LIVING OF WEST SAN JOSE	FACILITY NUMBER: 435202895
	VISIT DATE: 12/07/2023

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The facility is equipped with fire alarm system, smoke and carbon monoxide detectors for each floor. Fire alarm and smoke detectors were tested by ADM and was observed to be in good working condition. Fire alarm exit route were observed and found to have nothing obstructing the walkways. LPAs observed 2 functioning elevator in the facility. The medication room and medication carts have locking mechanisms and medication carts will be stored in the wellness office at the end of each day.

Component III was conducted with ADM. LPAs answered ADM's questions.

No deficiency noted today 12/07/2023. Exit interview was conducted with ADM. The report was provided to ADM for signature. A copy of the report was provided to ADM.

Page 2 of 2.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2