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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202895
Report Date: 01/24/2025
Date Signed: 01/24/2025 05:17:00 PM

Document Has Been Signed on 01/24/2025 05:17 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:MORNINGSTAR ASSISTED LIVING OF WEST SAN JOSEFACILITY NUMBER:
435202895
ADMINISTRATOR/
DIRECTOR:
WELCH, JOYCEFACILITY TYPE:
740
ADDRESS:1380 S DEANZA BLVDTELEPHONE:
(669) 295-6500
CITY:SAN JOSESTATE: CAZIP CODE:
95129
CAPACITY: 149CENSUS: 80DATE:
01/24/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:35 PM
MET WITH:Joyce WelchTIME VISIT/
INSPECTION COMPLETED:
04:32 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 Analysts (LPAs) Steve Chang and Kenneth Madrigal conducted an unannounced case management - incident visit and met with Executive Director (ED) Joyce Welch.

On 1/21/2025, the Department received an incident report that on 1/18/2025, a resident (R1) was found not in the facility around 12:50PM. R1 was last seen in the facility around 11:00AM. Based on the footage of the surveillance camera system, R1 left the facility around 12:00PM. The facility notified R1's family and Police Department. R1 was found walking on the street around 1:09PM without injury.

LPA interviewed ED, 2 staff (S1, S2). LPAs toured the facility with ED. LPAs interviewed resident R1 and R1's family member. ED stated the police officers did not provide the police report case number. ED stated this is R1's first time elopement incident. LPAs checked the facility delayed egress door system of memory care unit.

LPA requested R1's physician report, appraisal needs and service plan.

This case management need further investigation.

Exit interview was conducted with ED. The report was provided to ED for review and signature. A copy of the report was provided to ED.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2025
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 1