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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200344
Report Date: 07/25/2022
Date Signed: 07/25/2022 12:05:53 PM

Document Has Been Signed on 07/25/2022 12:05 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:FORUM AT RANCHO SAN ANTONIO, THEFACILITY NUMBER:
435200344
ADMINISTRATOR:NANCY KAOFACILITY TYPE:
741
ADDRESS:23500 CRISTO REY DRIVETELEPHONE:
(650) 944-0100
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY: 791CENSUS: 54DATE:
07/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Rosalie HulogTIME COMPLETED:
12:15 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 Assisted Living Director, Rosalie Hulog and Resident Service Director, Dana Graefe.

During visit, LPA toured the facility's assisted living and memory care unit located inside the Healthcare center. All fire exit routes were free and clear of obstruction. All staff observed wearing a face mask. All staff are N95 fit tested.

Prior to entering the community, a screening station was observed at the main entrance to include COVID-19 symptom screening, temperature check, and proof of vaccination and/or a negative COVID-19 test. Facility's Healthcare center has a central entry point to also include symptom screening and temperature check for all visitors and staff. Hand washing station observed at the entry and hand sanitizer observed available throughout the facility. Facility's visitation sign and mask required posted at the front entrance. Restrooms and hand washing areas supplied with hygiene products, paper supplies, and hand washing sign. LPA observed the facility's Personal Protective Equipment (PPE) supplies. Facility staff clean and disinfect multiple times daily and as needed. The following signs were observed to include, cough etiquette, social distancing, symptoms of COVID, hand washing, and donning and doffing.

LPA reviewed facility's procedures to isolation and infection control training to include PPE use.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Assisted Living Director, Rosalie Hulog, Resident Service Director, Dana Graefe, and Executive Director, Nancy Kao and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2022
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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