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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275294182
Report Date: 01/20/2021
Date Signed: 02/03/2021 08:11:42 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:DRAKE HOUSEFACILITY NUMBER:
275294182
ADMINISTRATOR:JULIE HUYNHFACILITY TYPE:
740
ADDRESS:399 DRAKE AVENUETELEPHONE:
(831) 643-9069
CITY:MONTEREYSTATE: CAZIP CODE:
93940
CAPACITY:55CENSUS: 46DATE:
01/20/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Julie HuynhTIME COMPLETED:
12:40 PM
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Licensing Program Analysts (LPA) Marybeth Donovan conducted a Technical Assist (TA) Visit via FaceTime with Julie Huynh Administrator and Barbie Henson 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, isolation protocols and social distancing.

The following recommendations were discussed:

1. Utilize written screening questionnaire for staff and visitors and document completion.
2. Post Isolation Room Signage outside each isolation room.
3. Post signage for Donning and Doffing of PPE outside and inside of designated isolation room(s).
4. Maintain hand sanitizer inside and outside of isolation room(s).
5. Maintain covered trash can inside isolation room(s) for PPE Disposal.

Signage for Donning and Doffing of PPE and Masks forwarded.

LPA reviewed report with Julie Huynh 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: 01/20/2021
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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