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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270708716
Report Date: 01/05/2021
Date Signed: 02/03/2021 08:16:28 AM

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:VISIONARY CARMEL-BY-THE-SEA ASSISTED LIVINGFACILITY NUMBER:
270708716
ADMINISTRATOR:CONNERS, MARGARET P.FACILITY TYPE:
740
ADDRESS:LINCOLN & 7TH STREETTELEPHONE:
(831) 644-9246
CITY:CARMELSTATE: CAZIP CODE:
93921
CAPACITY:10CENSUS: 10DATE:
01/05/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Angelique RobinsonTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted a Technical Assist (TA) Visit via Zoom platform with Angelique Robinson Administrator and Angela Pruitt RN, MSN, Health Facilities Evaluator Nurse (HFEN) California Department of Public Health. The purpose of the visit was to provide technical assistance for Infection Prevention and Control guidelines for Adult and Senior Care facilities.

LPA conducted a virtual tour of the facility. LPA and HFEN reviewed the facility policies and procedures to include screening, disinfecting, supplies, staffing, training, PPE usage and social distancing.

The following recommendations were discussed:

1. Maintain covered trash can inside isolation room(s) for PPE Disposal.
2. Post signage for Donning and Doffing of PPE outside and inside of designated isolation room(s).
3. Supervise residents to maintain social distancing minimum of 6 feet.

Informational Links and websites were provided to include Tying the Face Mask, PPE Burn Calculator, PPE Eye Protection, UCSF Donning/Doffing PPE, Seal Check for N95 Mask, Return to Work, Cleaning and Testing.

LPA reviewed report with Angelique Robinson Administrator and copy emailed for signature purposes.
SUPERVISOR'S NAME: George NwaforTELEPHONE: (650) 269-7419
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE:
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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