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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275200997
Report Date: 02/07/2022
Date Signed: 02/08/2022 09:17:36 AM

Document Has Been Signed on 02/08/2022 09:17 AM - 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:CAUNTAY BOARD AND CARE HOMEFACILITY NUMBER:
275200997
ADMINISTRATOR:CAUNTAY, GAUDIOSAFACILITY TYPE:
735
ADDRESS:944 ESTRADA WAYTELEPHONE:
(831) 422-1845
CITY:SALINASSTATE: CAZIP CODE:
93907
CAPACITY: 6CENSUS: 5DATE:
02/07/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Gaudiosa CauntayTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Steve Chang, and Program Clinical Consultant (PCC) Cristina Wong conducted Technical Assistant - PCC through tele-inspection (Zoom),and met with Administrator (ADM) Gaudiosa Cauntay.

The purpose of this TA PCC Tele visit was to review the facility COVID-19 infection mitigation plan and conducted inspection of the facility to ensure plan is being carried out and to provide support and guidance to staff in mitigating the spread of virus.

During tele-visit inspection, a tour of the facility was conducted which started at the main entrance to check COVID-19 signage and screening procedures. The facility has the COVID-19 posters at the main entrance including screening questionnaire forms, hand sanitizer, face masks, thermometer, glove, and a visitor log book at the screening station.
Two staff were observed in facility.

The facility common areas were inspected such as the kitchen, living room, dinning area, bathrooms were observed. There are 3 resident shared bedrooms, 1 staff live-in bedroom, and 2 bathrooms in facility. Trash cans with covers, paper towels with holders, and washing hands signs by the sinks were observed. The laundry room was observed and inspected. The resident bedrooms were inspected. The beds in the shared rooms were observed in 6 feet apart.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2022
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: CAUNTAY BOARD AND CARE HOME
FACILITY NUMBER: 275200997
VISIT DATE: 02/07/2022
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Based on today's inspection, the facility is being recommended the following:

1. Facility to wipe and disinfect high touch areas more often.
2. Separate the laundry loads for positive and negative cases.
3. Use high hot temperature with laundry machine for COVID positive cases.
4. Facility to check body temperature at least 3 times per day for residents and staff.
5. Facility should not use common towels in bathrooms and kitchen due to contamination.
6. Facility to conduct staff training at least monthly or frequently such as donning and doffing PPE and COVID -19 updates.
7. Facility use of N95 mask by staff must have completed N95 mask fitting test
8. Facility to review PINs (Providers’ Information Notification) through CCLD website: www.ccld.ca.gov, and check PIN ASC 21-10 for N95 fitting test.
9. Facility to review the information for the links provided by LPA via email.

No deficiencies cited during today's Tele Visit. Exit interview conducted with Administrator.
A copy of this report emailed to the facility for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022
LIC809 (FAS) - (06/04)
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