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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202724
Report Date: 07/28/2022
Date Signed: 07/28/2022 02:29:48 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/28/2022 02:29 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:GOLDWOOD SENIOR CARE HOMEFACILITY NUMBER:
435202724
ADMINISTRATOR:JEANETTE MONGEONFACILITY TYPE:
740
ADDRESS:2692 GOLDWOOD CTTELEPHONE:
(669) 234-3544
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 6DATE:
07/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Irish LadwigTIME 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 Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Irish Ladwig. Upon arrival, Staff Maelena Pastrana (S1) took LPA body temperature, and checked LPA in the visitor log book.

LPA toured the facility inside out with ADM. COVID posters were observed at main entrance and in the facility. Screening station with masks, hand sanitizer, thermometer and visitor log book was observed at the main entrance. Family room, kitchen, dinning room and two restrooms were inspected. Not all trash cans were observed with covers. ADM stated the facility will put all the trash cans with covers in facility. Paper towels were observed with holders. Two single resident bedrooms, two shared resident bedrooms and laundry room were inspected. The beds in one of the shared rooms were not in 6 feet apart. ADM stated the facility will put the beds in shared room in 6 feet apart. One staff live-in room is in facility.Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 76 degree F, and hot water temperature was at 110 degree F in facility. Six residents and 2 staff were observed in facility.

Fire extinguisher was serviced on 03/22/2022. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

ADM stated all the residents and staff are fully vaccinated and done with booster. No deficiency or citation were noted today. Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2022
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 1