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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202950
Report Date: 08/07/2024
Date Signed: 08/07/2024 11:46:59 AM

Document Has Been Signed on 08/07/2024 11:46 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:ROXBURY ELDERLY CARE LLCFACILITY NUMBER:
435202950
ADMINISTRATOR/
DIRECTOR:		LI, TINGXIUFACILITY TYPE:
740
ADDRESS:515 ROXBURY LNTELEPHONE:
(408) 809-6806
CITY:LOS GATOSSTATE: CAZIP CODE:
95032
CAPACITY: 6CENSUS: 0DATE:
08/07/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:LI, TINGXIUTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
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) Christine Dolores, Marcela Yanez, and Kiran Jain arrived announced to conduct the pre-licensing inspection. LPA met with Tingxiu Li.

The facility has an approved fire clearance for (6) non-ambulatory with a hospice waiver granted for (6) residents.

During visit, LPAs toured the interior to include 4 resident bedrooms, 1 staff bedroom, 2 bathrooms, living room, kitchen, garage, backyard, and front yard. All fire exit routes are free and clear of obstruction. Fire extinguisher, carbon monoxide detector, and complete first aid kit observed present. No emergency lighting present at the facility during inspection. Ting ordered the emergency lighting during visit. The backyard contains a shed and observed with storage items. Hot tub observed filled with water and observed covered and locked. Front porch observed with a pond that is drained and contains wood that fills the inside.

Interior temperature maintained between 74 - 76 degrees Fahrenheit. Kitchen is equipped with cabinets that has child locks to store items that will be kept inaccessible to residents. Ting was advised to ensure the cabinets contains more secure locks. Sufficient cups, plates, bowls, and utensils observed. Refrigerator temperature maintained at 32 degrees Fahrenheit. Freezer temperature maintained at 0 degrees Fahrenheit. Bedrooms equipped with beds, linens, adequate lighting, chair, night-stand, and dresser. All beds contains half rails and 1 bed observed with full rails. Ting states the residents who will be admitted to the facility will contain a physician's report for half or full rails.
SEE LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2024
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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: ROXBURY ELDERLY CARE LLC
FACILITY NUMBER: 435202950
VISIT DATE: 08/07/2024
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
26
27
28
29
30
31
32
Hot water temperature in the bathroom maintained at 106 degrees Fahrenheit. Bathroom shower does not contain a non-slip mat. Ting purchased the non-slip mat during visit. Bathroom toilet does not contain grab bars. Ting states a plan to input a handicap rising toilet that contains grab bars. Garage observed with laundry appliances and supplies. Facility has an area to lock medications and records. Posters observed to include the licensing complaint poster, personal rights and rights of resident council. Ting was advised to ensure the emergency disaster plan and theft and loss policy is posted.

COMP III was waived as the applicant is the licensee/administrator of another care facility.

No issues noted during the pre-licensing inspection. LPA observed the facility is ready to be licensed. However, this report will be submitted to the Central Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

This report was reviewed with Tingxiu Li and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2