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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202822
Report Date: 07/20/2021
Date Signed: 07/20/2021 02:43:31 PM

Document Has Been Signed on 07/20/2021 02:43 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:HILLSDALE SENIOR LIVINGFACILITY NUMBER:
435202822
ADMINISTRATOR:LADWIG, JUSTINFACILITY TYPE:
740
ADDRESS:1538 HILLSDALE AVE.TELEPHONE:
(408) 914-1147
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY: 6CENSUS: 0DATE:
07/20/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Irish Ladwig and Justin LadwigTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Joanne Roadilla conducted a pre-licensing inspection today. LPA met with Administrator (ADM) Justin and Irish Ladwig.

At around 1:35pm, LPA toured the facility inside and out. A screening station is observed by the entry door for anyone coming in the facility.

The facility is equipped with connected smoke detectors. The smoke detector located in the hallway by the entry was tested and observed working. A carbon monoxide detector located next to room #3 was tested and observed working. A fire extinguisher was observed in the kitchen which ADM reported was bought in May 2021. The kitchen, dining and living room were observed in good repair.

Resident bedrooms were observed in good repair, furnished, with clean linens and adequate lighting. Bathrooms were observed clean and equipped with grab bars and non-skid mats. The water temperature in bathroom #2 was measured at 120 degrees F. Centrally stored medication cabinet, and a cabinet with non-perishable and emergency food supplies and PPEs were observed in the kitchen. A complete first aid kit was inspected. The backyard was inspected. All outdoor and indoor passageways were observed clear and free of obstruction. No bodies of water observed.

Component III orientation was waived for this facility due to Administrator’s background and experience. No issues noted during the pre-licensing tele-inspection. The physical plant is approved pending the completion of Centralized Application Bureau (CAB) review of the facility application. Exit interview conducted with and copy of report provided to Justin and Irish Ladwig.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Joanne Roadilla
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2021
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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