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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294192
Report Date: 08/24/2021
Date Signed: 08/24/2021 06:32:11 PM

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:A HOME AT SHAWFACILITY NUMBER:
435294192
ADMINISTRATOR:BELTRAN, SERAPIA D.FACILITY TYPE:
740
ADDRESS:1545 SHAW DRIVETELEPHONE:
(408) 960-8847
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY:6CENSUS: 6DATE:
08/24/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
05:30 PM
MET WITH:Gladys SmartTIME COMPLETED:
06:00 PM
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Licensing Program Analyst (LPA) Joanne Roadilla conducted an unannounced Case Management tele-visit at the facility today. The facility is licensed to serve 6 residents 60 years and over, 5 may be non-ambulatory and 1 may be bedridden. The facility has been granted a hospice waiver for four (4). LPA met with Administrator (ADM) Gladys Smart and discussed the purpose of the visit.

On 08/19/21, ADM submitted a request for an exception to retain a resident (R1) who has been diagnosed as bedridden and dependent on others for all activities of daily living (ADLs).

At 5:35pm, LPA conducted a virtual tour of R1’s shared bedroom via FaceTime with ADM and a facility staff. LPA observed that R1 is not able to reposition and is bedridden. LPA also observed that R1 is not capable of grooming oneself. ADM and staff stated R1 is not able to perform any other ADLs without caregiver assistance.

LPA reviewed R1's files including physician's reports (LIC602A), appraisal/needs and services plan (LIC625) and functional capability assessment (LIC9172) and discussed with ADM during the visit.

No deficiency cited during today's tele-visit. LPA provided a Technical Assistance during today's tele-visit, see LIC9102. A copy of the report was discussed with and provided to Gladys Smart via e-mail for review and signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne RoadillaTELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
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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