275200750-1-22-2021-26-AS-GDAS-BXJ2SQ-20210122163931

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 275200750
Report Date: 01/22/2021
Date Signed: 01/22/2021 04:40:19 PM

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:	SANTO NINO RESIDENTIAL CARE HOME		FACILITY NUMBER:	275200750
ADMINISTRATOR:	FONTEJON, DOMINADOR		FACILITY TYPE:	740
ADDRESS:	965 HANCOCK ST.		TELEPHONE:	(831) 443-9573
CITY:	SALINAS	STATE: CA	ZIP CODE:	93906
CAPACITY:	6	CENSUS: 3	DATE:	01/22/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	09:53 AM
MET WITH:	Dominador Fontejon		TIME COMPLETED:	10:40 AM

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) Grace Davis conducted a Technical Assistance tele-visit to prevent and mitigate the spread of COVID-19 at the facility via ZOOM. Due to COVID-19 preventive measures, facility visits have been suspended. LPA met with Administrator (ADM) Dominador Fontejon and also present is Health Facility Evaluator Nurse (HFEN) Janet Hayes. The facility census is 3 including 1 hospice. 2 Of 3 residents are covid-19 positive. One is isolating on her room and one is in Skilled nursing facility. ADM is in contact with Monterey Local Public Health. During today's inspection, the facility was virtually toured. LPA observed three staff are wearing N95. The facility has signage of COVID-19 in the main door and common areas. Facility is not admitting visitors except essential workers (medical professionals). Residents are using Zoom and video chat to communicate with their family.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Grace Davis	TELEPHONE: (408) 314-5102
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2021

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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SANTO NINO RESIDENTIAL CARE HOME	FACILITY NUMBER: 275200750
	VISIT DATE: 01/22/2021

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HFEN nurse Recommendations:

§ Follow up to ensure response testing has been completed for all residents and staff who have not tested positive in the last 90 days.
§ Once response testing is completed, surveillance testing of 25% of staff each week, who have not tested positive in the last 90 days.
§ Ensure adequate supply of PPE, specifically N95s and gowns. Plan to extend use wear of N95s for 2 days to ensure adequate availability. Place N95 in paper bag when not in use and discard after second day of wear. Dispose of gowns on exit of the room after completing care in COVID+ residents.

No deficiencies observed during this visit. Exit Interview conducted with ADM. A copy of this report is e-mailed to the facility for signature.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Grace Davis	TELEPHONE: (408) 314-5102
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2021

LIC809 (FAS) - (06/04)

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