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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600734
Report Date: 02/18/2021
Date Signed: 03/04/2021 08:24:41 AM

Document Has Been Signed on 03/04/2021 08:24 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:GONZALES HOMEFACILITY NUMBER:
415600734
ADMINISTRATOR:GONZALES, ROGELIO & PROSPEFACILITY TYPE:
740
ADDRESS:3645 FLEETWOOD DRIVETELEPHONE:
(650) 589-8820
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 6CENSUS: 5DATE:
02/18/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Prosperidad GonzalesTIME COMPLETED:
03:15 PM
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On this date, Licensing Program Analyst (LPA) Michael Garcia conducted a Case Management tele-visit to conduct a Technical Assistance (TA) to the facility regarding COVID-19 with the assistance of Barbie Henson, RN, Health Facilities Evaluator Nurse of the California Department of Public Health. The tele-visit was conducted with Prosperidad Gonzales, administrator.

The facility's COVID-19 protocol was discussed. The inside premises of the facility were toured.

According to Prosperidad, a staff tested positive for COVID-19 and is in self-isolation outside the facility. All other staff and residents are not showing symptoms of COVID-19. Staff testing for COVID-19 is scheduled for tomorrow. Prosperidad is coordinating COVID-19 testing for residents.

The TA visit resulted with the following recommendations:
- Ensure all staff and residents are tested for COVID-19 as soon as possible.
- Remove COVID-19 droplet precautionary signs from the facility's main door.
- Screen for additional symptoms of COVID-19 as described in PIN 20-07 ASC (provided) and document the screening process.
- Screen staff for COVID-19 symptoms before and after each shift.
- Prepare movable cart to store PPE supplies.
- Ensure all trash cans have lids, foot operated or handsfree, and are easily accessible.


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SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Michael Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 02/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: GONZALES HOME
FACILITY NUMBER: 415600734
VISIT DATE: 02/18/2021
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- Provide in-service training for staff on how to properly use PPEs and have staff demonstrate back.
- Post proper hand washing signs (provided) on each hand washing stations/sinks.
- Post proper donning instruction (provided) outside of each COVID-19 positive resident's door, if any.
- Post proper doffing instruction (provided) inside of each COVID-19 positive resident's door, if any.
- Remove four (4) chairs at the dining table and any excess chairs at the facility or have the excess chairs inaccessible to foster physical distancing.
- Ensure residents' beds are at least 6ft apart as described in PIN 20-23 ASC (provided).
- Ensure staff wear full PPE (N95, face shield/goggle, gown, gloves) when doing laundry or providing care for COVID-19 positive residents, if any.
- Use hot water when doing laundry for COVID-19 positive resident, if any, and disinfect the inside and outside of the washing machines/dryer after each use.
- Ensure all staff and residents are tested for COVID-19 as described in PIN 20-23 ASC (provided).

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

Report was reviewed and discussed with Prosperidad at the end of the visit.

An electronic copy of the report was emailed to Prosperidad for signature.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Michael Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2021
LIC809 (FAS) - (06/04)
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