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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708102
Report Date: 08/19/2022
Date Signed: 08/19/2022 02:07:08 PM


Document Has Been Signed on 08/19/2022 02:07 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:MERTZ CARE HOMEFACILITY NUMBER:
430708102
ADMINISTRATOR:MERTZ, ELVIRAFACILITY TYPE:
740
ADDRESS:2715 MCLAUGHLIN AVENUETELEPHONE:
(408) 483-2748
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY:6CENSUS: 2DATE:
08/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Chelsea PlazaTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection to focus on infection control. LPA met with Direct Care Staff, Chelsea Plaza.

During visit, LPA toured the inside and outside of the facility to include the kitchen, dining room, living room, resident rooms, bathrooms, and backyard. All fire exit routes were free and clear of obstruction. The swimming pool was observed inaccessible and locked. Staff observed to be wearing a face mask.

Facility has a central entry point for COVID-19 symptom screening, temperature check, and sign-in. LPA advised to create a symptom screening log for all staff and visitors. Hand sanitizer made available. Bathrooms supplied with hygiene products, paper supplies, and hand washing sign. Facility staff clean and disinfect multiple times daily and as needed. Staff monitor residents temperature and symptoms multiple times day. LPA observed facility's Personal Protective Equipment (PPE) supplies. Trash bins observed with lid. Staff have not completed N95 fit-testing. The following signs were posted to include symptoms of COVID, face mask required, social distancing, stop the spread of germs, and droplet precaution. LPA reviewed facility's procedures to isolation, training, and visitation.

No deficiencies were cited per California Code of Regulations, Title 22. Advisory notes provided.

This report was reviewed with Direct Care Staff, Chelsea Plaza and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2022
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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