015601501-9-22-2021-15-AS-DPAO-C74QZT-20210922123717

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601501
Report Date: 09/22/2021
Date Signed: 09/22/2021 12:37:30 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	LANDMARK VILLA		FACILITY NUMBER:	015601501
ADMINISTRATOR:	DIANE PEDERSON		FACILITY TYPE:	740
ADDRESS:	21000 MISSION BLVD.		TELEPHONE:	(510) 276-2872
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	140	CENSUS: 72	DATE:	09/22/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Diane Pederson, Administrator		TIME COMPLETED:	12:40 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	On 09/22/21 at 11:15 AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an infection control annual inspection and explained the purpose of the visit with administrator. Facility is a three story building with 97 apartments with in room showers/toilets and kitchen. LPA observed 16 staff wearing face masks during visit with 14 residents eating lunch (2 per table) in the first floor dining room. LPA observed screening station located near the front entrance with visitor's log, COVD-19 questionnaire, hand sanitizer, gloves, face masks and no touch temperature probe. Routine symptom screening (+/-) temperature and symptom checks are done at entry for all staff, residents and visitors. Facility has a completed mitigation plan in place dated 04/12/2021 to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) with administrator as well as COVID-19 infection control practices. Common toilets (male and female) were observed on each floor with adequate supply of paper towels and soap. LPA inspected the facility inside and outside. LPA observed COVID-19 signages posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks for staff and residents. Pathways were observed to be free of obstruction and fire hazards. Facility has a visitation area next to the dining room. Dining room had tables spaced six feet apart for social distancing among residents. Continued on next page LIC 809-C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LANDMARK VILLA	FACILITY NUMBER: 015601501
	VISIT DATE: 09/22/2021

NARRATIVE

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A written Emergency/Disaster plan dated 05/13/2021 was posted near the front desk. Centrally stored medications were locked in the medication room. Sharp objects were also locked in the medication room. Toxic chemicals were locked in the housekeeping storage room. Adequate supply of PPE was observed stored in the second floor storage closet. Facility has conducted staff training on infection prevention, symptoms, transmission and proper donning & doffing of PPE. Trash bins with lid operated foot pedal was observed in the first floor employees' toilet room.

Infection control designated leader is the administrator. 95 percent of staff and residents have been fully vaccinated since February 2021. There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency food supplies were observed stored in the kitchen and basement. Facility room temperature was maintained at 73 degrees Fahrenheit. A certified administrator is on site a minimum of 20 hours a week to oversee proper business operation and compliance with COVID-19 infection control practices. Fire extinguisher was observed fully charged. Smoke and Carbon monoxide detectors were operational.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 09/23/2021:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610E- Emergency/Disaster Plan
· Evidence of Liability Insurance

No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided to administrator.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021

LIC809 (FAS) - (06/04)

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