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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275294335
Report Date: 09/27/2021
Date Signed: 09/30/2021 08:15:43 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:AVE MARIA RCFE #1FACILITY NUMBER:
275294335
ADMINISTRATOR:BARBARA REIDFACILITY TYPE:
740
ADDRESS:1249 JOSSELYN CANYON ROADTELEPHONE:
(831) 373-1216
CITY:MONTEREYSTATE: CAZIP CODE:
93940
CAPACITY:49CENSUS: 9DATE:
09/27/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ruth ElliotTIME COMPLETED:
01:45 PM
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LPA Marybeth Donovan conducted a TA Visit with Lori Kopplinger Program Clinical Consultant (PCC), Jackie Jin LPM, and Ruth Elliot Assisted Living Director. 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 tour of the facility.

LPA and PCC reviewed the facility policies and procedures to include screening, visitation and social distancing, isolation, staffing, training, PPE usage, Doffing and Donning of PPE, Fit Testing, and disinfecting.

The following recommendations were discussed:

1. Utilize One Entry Point for All to include residents, visitors and staff
2. Utilize updated COVID Symptom screening list
3. Post hand washing signs next to sinks
4. Maintain Emergency PPE cart available for immediate usage
5. Conduct additional PPE Donning and Doffing Training to include return demonstration by user

LPA provided Link to CDC COVID 19 Symptoms, Poster of the PPE Donning and Doffing and Provider Information Notification (PIN) 21-17.2 ASC.

RO to provide additional supply of PPEs to the facility.

LPA reviewed recommendations with Ruth Elliot Assisted Living Director and copy emailed for signature.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021
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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