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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202569
Report Date: 11/18/2021
Date Signed: 11/18/2021 10:59:58 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:CAREFIELD AT MADONNA GARDENSFACILITY NUMBER:
275202569
ADMINISTRATOR:PATRICIA KINGFACILITY TYPE:
740
ADDRESS:1335 BYRON DRTELEPHONE:
(831) 758-0931
CITY:SALINASSTATE: CAZIP CODE:
93901
CAPACITY:88CENSUS: 46DATE:
11/18/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Patricia KingTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) David Marrufo, Licensing Program Manager (LPM) Sarah Yip, and Nurse Lori Kopplinger conducted a tele-visit via Zoom to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility. LPA Marrufo, and Nurse Lori Kopplinger met with Administrator Patricia King.

The Administrator reports that there are currently 11 COVID-19 positive residents and 0 COVID-19 positive staff.

During today's tele-visit, the following recommendations were made to the facility by Nurse Lori Kopplinger:

1. Put trash cans with lids in facility entrance bathroom.
2. Have staff be fit tested for N95s.
3. Face shields with forehead foam cushions should be disposed of after use.
4. Meal service transporters should be in full PPEs when entering Memory Care.
5. Move PPE Donning Station to near food tray and PPE Doffing Station should be outside or near the outside of the facility.


No deficiencies were cited as per California Code of Regulations, Title 22. This report was reviewed with with Administrator Patricia King. A copy of the report will be sent to her for it to be signed and returned to CCL.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
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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