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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707868
Report Date: 12/23/2021
Date Signed: 12/23/2021 10:58:32 AM

Document Has Been Signed on 12/23/2021 10:58 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:FLORENCE RESIDENTIAL CARE HOME #2FACILITY NUMBER:
430707868
ADMINISTRATOR:PERLA DIMALANTA ZEIJNALIFACILITY TYPE:
735
ADDRESS:135 NORTH 8TH STREETTELEPHONE:
(408) 293-0362
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY: 10CENSUS: 8DATE:
12/23/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Perla ZeijnaliTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) David Marrufo, Licensing Program Manager (LPM) Jackie Jin, and Nurse Rozane Fangon conducted a tele-visit via Zoom to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility and met with Administrator Perla Zeijnali.

The Administrator reports that there are currently 3 COVID-19 positive residents and 0 COVID-19 positive staff.

During today's tele-visit, the following recommendations were made to the facility by Nurse Roxane Fangon:

1. Train staff on how to properly don and doff PPEs
2. Train staff on how to use visitor screening form
3. Install a lock on desk drawers for storing records and screening materials
4. Train staff to use daily staff screening logs
5. Separate chairs at dinner tables and living room
6. Set up a fold up table in living room during meals.
7. Train staff to check temperatures and symptoms in isolation room
8. Provide PPE cart for isolation rooms
9. Fit test staff to be properly sized for N95 masks

No deficiencies were cited as per California Code of Regulations, Title 22.

This report was reviewed with with Administrator Perla Zeijnali. A copy of the report will be sent to her for it to be signed and returned to CCL.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2021
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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