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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600033
Report Date: 01/15/2021
Date Signed: 01/15/2021 02:23:48 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:MILLS ESTATE VILLAFACILITY NUMBER:
415600033
ADMINISTRATOR:MONTANO, DELIA GODOYFACILITY TYPE:
740
ADDRESS:1733 CALIFORNIA DRIVETELEPHONE:
(650) 692-0600
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY:47CENSUS: 32DATE:
01/15/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Delia MontanoTIME COMPLETED:
01:25 PM
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On this date, Licensing Program Analyst (LPA) Michael Garcia conducted a follow-up Case Management tele-visit to provide Technical Assistance (TA) to the facility regarding COVID-19 with the assistance of Roxane Fangon, RN, program clinical consultant. The TA was conducted with Delia Montano, executive director/administrator.

According to administrator, the facility continues to have weekly COVID-19 positive test results between staff and residents since the beginning of the outbreak. The facility's COVID-19 screening protocol was reviewed. Some common areas of the facility were toured.

The TA visit resulted with the following recommendations:
- Conduct COVID-19 screening of residents every 8 hours.
- Ensure all trash cans have lids.
- Remove cloth towels on common restrooms.
- Disinfect face shields with EPA approved solutions before and after usage.
- Do not use the same face shield longer than 28 days.
- Store face shields inside a paper bag when not in use.
- Pause using electrostatic machine at this time. Use Lysol or other EPA approved cleaning solutions until further notice.
- Designate a separate break room for staff dedicated to COVID-19 positive residents.
- Ensure dedicated staff do not mingle with negative staff and residents.
- Ensure washing machines and dryers are disinfected inside and outside after each use for COVID-19 residents.
- Ensure staff are doffing properly inside the room of the COVID-19 positive resident.
- Please communicate with Local Public Health for more guidance.

Administrator shall ensure to submit a signed and dated action plan to LPA via email regarding the above recommendations within 24 hours.

Report was discussed with administrator at the end of the visit. An electronic copy of the report was emailed to administrator for signature.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Michael GarciaTELEPHONE: (650) 380-4608
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2021
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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