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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202412
Report Date: 08/04/2020
Date Signed: 08/04/2020 01:59:21 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:MERIDIAN MANOR 3 SPECIAL RES FAC FOR ELDERLY(RCFE)FACILITY NUMBER:
435202412
ADMINISTRATOR:DAVE MAGNOFACILITY TYPE:
740
ADDRESS:345 BURNETT AVE.TELEPHONE:
(408) 772-0339
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY:4CENSUS: 4DATE:
08/04/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:57 AM
MET WITH:Dave MagnoTIME COMPLETED:
12:20 PM
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On August 4, 2020 at 11:57am, Licensing Program Analyst (LPA) Karen Taku conducted an unannounced Case Management Tele-Visit, via FACETIME. Due to COVID19 preventative measures, the Department has suspended on-site visits. LPA spoke with Administrator Dave Mango.

The purpose of today’s visit is to assess whether R1 requires assistance with all Activities of Daily Living (ADL). Such as, bathing, dressing, toileting, transferring, continence, and eating.

At 12:05 LPA observed R1 napping upright in wheelchair.

No deficiencies cited during today’s visit.

This report was discussed, and a copy was provided to the Administrator via email for signature.



SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Karen TakuTELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2020
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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