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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601085
Report Date: 07/07/2021
Date Signed: 07/07/2021 06:09:18 PM

Document Has Been Signed on 07/07/2021 06:09 PM - 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:HEARTS AT MILLWOOD ASSISTED LIVINGFACILITY NUMBER:
415601085
ADMINISTRATOR:ERMITANO, ELAINE B.FACILITY TYPE:
740
ADDRESS:416 MILLWOOD DRTELEPHONE:
(415) 624-4654
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY: 6CENSUS: 5DATE:
07/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:44 PM
MET WITH:Elaine ErmitanoTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Gladys Kuizon conducted an annual inspection today and met with Administrator Elaine Ermitano.

LPA entered the facility through the facility's central entry point. 1 resident was observed watching TV in the living room. LPA was screened by staff upon entrance. At 12:51 PM, a tour of the facility was conducted. The facility's screening procedures were reviewed. COVID-19 postings including hand-washing and infection control guides were observed throughout the facility including on the main entrance, hallways, and bathrooms. Staff were observed wearing face coverings.

The facility has a supply of personal protective equipment (PPE) including face shields, isolation gowns, gloves, and face masks. Hand sanitizers, soap, and single use hand towels were observed available. The facility has at least 30 days' supply of residents' medications. At least 2 days' supply of perishable food and at least 1 week's supply on non-perishable food supply was observed in the premises.

Per Administrator, all residents and staff are fully vaccinated against COVID-19. The facility is currently accepting visitors inside the facility. A designated visitation area is available.

Exit routes were observed clear and unobstructed. No open bodies of water were observed. Resident roster with current emergency contact information is available.

The facility's COVID-19 mitigation plan was reviewed and discussed with Administrator.

No deficiencies were cited. Exit interview conducted with Administrator and a copy of this report was provided during visit.
SUPERVISORS NAME: George Nwafor
LICENSING EVALUATOR NAME: Gladys Kuizon
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2021
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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