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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200344
Report Date: 09/23/2020
Date Signed: 09/23/2020 03:36:25 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:FORUM AT RANCHO SAN ANTONIO, THEFACILITY NUMBER:
435200344
ADMINISTRATOR:NANCY KAOFACILITY TYPE:
741
ADDRESS:23500 CRISTO REY DRIVETELEPHONE:
(650) 944-0112
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY:743CENSUS: 57DATE:
09/23/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Rosalie HulogTIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Joanne Roadilla conducted an unannounced Case Management tele-visit via FaceTime today. The Department has suspended on site visits due to COVID-19 shelter in place order by Governor Newsom. LPA met with Assisted Living Manager (ALM) Rosalie Hulog.

The purpose of the tele-visit was to ensure the facility is continuing to adhere to COVID-19 infection control guidelines and preventive measures.

At 2:25pm, LPA toured the facility entrance and the memory care (MC) unit. LPA observed one resident at the MC unit eating by the bistro area. A staff assisting the resident eat was observed wearing a mask. A hand washing station was observed available for staff and residents. A single wall mounted hand sanitizer dispenser was observed by the bistro, accessible to staff and residents in care. ALM stated they do not have a resident with wandering behavior at the MC unit. ALM also stated that for residents who require 1:1 care, someone is always with the resident, so no one is at risk of ingesting the sanitizer. ALM reported that facility is now conducting surveillance testing of 25% of staff every week.

No deficiencies cited during today's tele-visit. Report was discussed with and a copy sent to Rosalie Hulog to sign and mail back to CCL.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne RoadillaTELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2020
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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