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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200344
Report Date: 07/22/2021
Date Signed: 07/22/2021 04:05:02 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:791CENSUS: 58DATE:
07/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Nancy KaoTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Joanne Roadilla conducted an unannounced Infection Control site visit today. LPA met with Executive Director (ED) Nancy Kao and Assisted Living Manager (ALM) Rosalie Hulog.

LPA toured the assisted living and memory care unit inside and out with ALM. Facility was observed to have a designated entry point for universal symptom screening including temperature check and a questionnaire log. Hand sanitizers were available throughout the facility and markers were observed to promote social distancing. All staff present were observed wearing masks.

Restrooms were observed supplied with hygiene products and with hand washing signs. The kitchen, dining room, common/activity rooms, and the exterior of the facility were also inspected. All fire exit routes were observed clear of obstruction. Medications are secured and only accessible to staff.

LPA reviewed the facility COVID-19 related infection control policies and procedures with ED and ALM including surveillance testing, disinfecting, staffing, training, isolation, PPE use and inventory. Facility has a COVID-19 mitigation plan in place.

No deficiencies issued per Title 22 of the California Code of Regulations. LPA reviewed report with and a copy provided to Nancy Kao.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne RoadillaTELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
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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