430708102-1-14-2022-26-AS-CCHG-CAP2VZ-20220114164446

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 430708102
Report Date: 01/14/2022
Date Signed: 01/14/2022 04:45:23 PM

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:	MERTZ CARE HOME		FACILITY NUMBER:	430708102
ADMINISTRATOR:	MERTZ, ELVIRA		FACILITY TYPE:	740
ADDRESS:	2715 MCLAUGHLIN AVENUE		TELEPHONE:	(408) 483-2748
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95121
CAPACITY:	6	CENSUS: 3	DATE:	01/14/2022
TYPE OF VISIT:	Case Management - Other	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Elvira Mertz		TIME COMPLETED:	10:30 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Steve Chang, licensing Program Manager (LPM) Jackie Jin, and Program Clinical Consultant (PCC) Roxane Tangon Technical Assistant - PCC through tele-inspection (Zoom). Met with Administrator (ADM) Elvira Mertz. The purpose of this TA PCC Tele visit is to review the facility COVID-19 infection mitigation plan and conducted inspection of the facility to ensure plan is being carried out and to provide support and guidance to staff in mitigating the spread of virus. During tele-visit inspection, a tour of the facility was conducted which started at the main entrance to check COVID-19 signage and screening procedures. The facility has the COVID-19 posters at the main entrance including screening questionnaire forms, hand sanitizer, face masks, thermometer, glove, and a visitor log book at the screening station. The facility common areas were inspected such as the kitchen, living room, family room, dinning area, bathrooms were observed. There are 3 resident shared bedrooms, and 2 bathrooms in facility. Trash cans with covers, paper towels with holders, and washing hands signs by the sinks were observed. PPE supplies were observed. isolation room was observed.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: MERTZ CARE HOME	FACILITY NUMBER: 430708102
	VISIT DATE: 01/14/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Based on today's inspection, the facility is being recommended the following:

1. Facility to wipe and disinfect high touch areas as frequently.

2. Facility to remove the extra chairs in dinning area.

3. Facility to have the dedicated PPE area for isolation room.

4. Facility to ensure that residents' soiled clothing/linens are separated between the positive and negative residents. For drying clothes, it should be in high heat temperature.

5. Please review the reference resources LPA sent by email.

No deficiencies cited during today's Tele Visit. Exit interview conducted with Administrator.
A copy of this report emailed to the facility for signature.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2