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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200157
Report Date: 03/09/2021
Date Signed: 03/11/2021 02:14:09 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:SANDY'S RESIDENTIAL CARE HOMEFACILITY NUMBER:
435200157
ADMINISTRATOR:ZIPAGAN, AZUCENAFACILITY TYPE:
740
ADDRESS:550 TUSCARORA DRIVETELEPHONE:
(408) 472-2059
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:6CENSUS: 4DATE:
03/09/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Sandy ZipaganTIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) Gladys Kuizon conducted a Technical Assistance (TA) tele-visit with CA Department of Public Health (CDPH) Health Facilities Evaluator Nurse (HFEN) Shahla Taleban. LPA and HFEN met with Administrator Sandy Zipagan.

At 10:44 AM, a video tour of the facility was conducted. The facility's current census is 4. COVID-19 information and guide posters were observed by the entrance and common areas of the facility. Hand hygiene supplies and personal protective equipment (PPE) supplies were observed available in the premises. The facility has screening procedures in place for all essential visitors and staff.

HFEN advised the following today:
1. Disinfection Procedures: Follow manufacturer's instructions when using disinfectants.
2. Screening Procedures: Post updated symptom list from Centers of Disease Control (CDC) by entrance and screening area.
3. HFEN recommends using trash bins with lids and foot pedals to minimize touching surfaces.
4. Encourage social distancing by configuring and/or marking seating furniture at least 6 feet apart.
5. Refrain from displaying and using reusable hand towels.
6. Conduct N-95 Fit Testing for all staff.

Per Administrator, all residents and staff received both doses of the COVID-19 vaccine as of February 12, 2021.

LPA reminded Administrator to continue surveillance testing for all COVID-19 negative staff and to continue to follow COVID-19 mitigation plan even after vaccination.

Continued, see LIC 809-C, page 2 of 2.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2021
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: SANDY'S RESIDENTIAL CARE HOME
FACILITY NUMBER: 435200157
VISIT DATE: 03/09/2021
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LPA also reminded Administrator to continue to review Provider Information Notices (PIN) to ensure up to date information from CCLD is received.

Per Administrator, all residents and staff received both doses of the COVID-19 vaccine as of February 12, 2021.

No deficiencies were cited today. A copy of this report was provided to Administrator via email for signature.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2021
LIC809 (FAS) - (06/04)
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