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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202961
Report Date: 03/05/2025
Date Signed: 03/05/2025 03:31:26 PM

Document Has Been Signed on 03/05/2025 03:31 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:ELLORE SENIOR LIVINGFACILITY NUMBER:
435202961
ADMINISTRATOR/
DIRECTOR:		AQUINO, JOYCEFACILITY TYPE:
740
ADDRESS:2350 CALLE DE LUNATELEPHONE:
(408) 755-6868
CITY:SANTA CLARASTATE: CAZIP CODE:
95054
CAPACITY: 303CENSUS: 0DATE:
03/05/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Applicants, Terry Ervin & Joyce AquinoTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Simi Rai arrived announced to conduct the facility's pre-licensing visit. LPA met with Applicants, Terry Ervin & Joyce Aquino and stated the purpose of today's visit. There are no residents present on site.

The facility has twenty (20) floors - floors four (4) to nineteen (19) consist of assisted living units, and floor three consist of memory care units. The facility has an approved fire clearance for 297 non ambulatory residents and 6 bedridden residents. Two out of two delayed egress doors were alarmed and in working condition.

LPA Rai observed a pool outside in the outside patio area on the twentieth (20th) floor. LPA Rai observed two doors leading to the pool outside; one door in the activity room and one door in the hallway next to the gym. LPA Rai observed both doors had locks on them which opened the fob key access. Applicants Terry and Joyce stated the staff are able to restrict the resident's access on the system. LPA Rai discusses California Code of Regulation (CCR) 87307(e)(2)(A) which states the licensee shall ensure that the bodies of water specified above are inaccessible through fencing, covering, or other means when not in active use by residents.

LPA toured the facility inside and outside including the apartments, bathrooms, kitchen, dinning room, stairwells and common areas. Resident rooms were equipped with proper furniture and lighting. LPA Rai observed the windows in the resident rooms and each window was restricted with bars on the side, the window opening up only approximately 5 to 6 inches. Facility temperature maintained at 73 degrees Fahrenheit. Bathrooms are equipped with grab bars, nonskid floors, hygiene supplies, and toiletry.

Continuation on LIC 809-C, Page 1 of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2025
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: ELLORE SENIOR LIVING
FACILITY NUMBER: 435202961
VISIT DATE: 03/05/2025
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Battery operated flashlights observed on-site. LPA Rai observed evacuation chairs on the 20th exit door in two of two stairwells. LPA Rai tested the carbon monoxide and smoke detector and it was in working condition. The fire extinguisher was inspected on 07/29/2024.

LPA observed supplies of perishable and non-perishable supplies. Refrigerator temperature was maintained at 35 degrees Fahrenheit. Freezer temperature was maintained at 0 degrees Fahrenheit. The kitchen does not have resident access and is separate from the dining area. LPA Rai observed emergency food and water supply at the facility. Facility kitchen is equipped with cups, plates, utensils, and cooking supplies. Hot water temperature was measured between 105.8 to 119.7 degrees Fahrenheit in the resident bathrooms.

The facility has designated medication rooms with locked medication cabinets. LPA observed first aid kit with the following supplies: bandages, scissors, tweezers, and thermometer.

The following posters observed to include the emergency telephone numbers, personal rights, RCFE compliant poster, complaint information, Rights of Resident Councils and Personal Rights of Residents in All Facilities.

COMP III was reviewed and completed with Applicants, Terry Ervin & Joyce Aquino.

No issues noted during this 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 Applicants, Terry Ervin & Joyce Aquino and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025
LIC809 (FAS) - (06/04)
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