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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200344
Report Date: 11/24/2020
Date Signed: 11/24/2020 03:49:18 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) 944-0100
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY:748CENSUS: 429DATE:
11/24/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Rosalie Hulog and Christine JeanTIME COMPLETED:
02:00 PM
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Licensing Program Analyst Joanne Roadilla and Health Facilities Evaluator Nurse (HFEN) Sheryll Falcone from the California Department of Public Health, conducted a tele-visit via Zoom to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility. LPA and HFEN met with Assisted Living Manager Rosalie Hulog and Wellness Manager Christine Jean, RN.

COVID-19 postings were visible throughout the facility. LPA/HFEN toured the assisted living side of the community, memory care unit, wellness center and the kitchen. HFEN identified the following areas of concern with infection control practices to prevent, contain, and mitigate the spread of COVID-19 at the facility:
1. During observation in the assisted living and memory care unit, there were two/three seater sofa and long benches that does not have a signage to keep people six feet apart. Recommended to block off sections of the seating in order to space people to promote social distancing.
2. Post signs in highly visible locations (e.g., at entrances, in restrooms, break room, activity area and dining area) that promote everyday protective measures and describe how to stop the spread (https://www.cdc.gov/coronavirus/2019-ncov/downloads/stop-the-spread-of-germs-11x17-en.pdf) of germs by properly washing hands and properly wearing a mask and social distancing.

This report was provided to Rosalie Hulog and Christine Jean for review and 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: 11/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2020
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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