435200605-11-20-2020-26-AS-GKUN-BVJVVZ-20201120154709

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435200605
Report Date: 11/20/2020
Date Signed: 11/20/2020 03:47:15 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:	ATRIA WILLOW GLEN		FACILITY NUMBER:	435200605
ADMINISTRATOR:	GURSU, UGUR (KURT)		FACILITY TYPE:	740
ADDRESS:	1660 GATON DR		TELEPHONE:	(408) 266-1660
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95125
CAPACITY:	63	CENSUS: 47	DATE:	11/20/2020
TYPE OF VISIT:	Office	ANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Kurt Gursu, Executive Director		TIME COMPLETED:	11:20 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	The San Bruno Regional Office - San Jose Unit held a joint conference call today with the CA Department of Public Health (CDPH) to collaborate with the facility and ensure concerns regarding COVID-19 Infection Control and Mitigation procedures are addressed and that the facility is able to comply. Community Care Licensing Division (CCLD) Regional Manager (RM) Vivien Helbling, Acting Assistant Program Administrator (AAPA) Krystall Moore, Program Clinical Consultant (PCC) Helen Shi, Licensing Program Analyst (LPA) Steve Nguyen, LPA Gladys Kuizon, and CDPH Health Facilities Evaluator Nurse (HFEN) Rebekah Bird-Wohlgemuth met with facility representatives Kurt Gursu (Executive Director), Jason Walthour (Regional Vice President), Jen Johnson (National Director of Care Management), and Jay Thomas (Assistant General Counsel). CCLD informed the facility of reports received by the Department regarding observations of stakeholders during on site visits. Concerns regarding entrance screening procedures, symptom checking, trash bins, communal dining, and hand hygiene were discussed. Executive Director (ED) stated the facility's response as follows: 1. Screening procedures: The facility has been following strict entrance screening protocols. Any visitor coming into the facility is screened at the main entrance building and once screening is completed, if a visitor is entering another building with a separate entrance, an associate will call staff at that building to advise that visitor has been screened and is approved to enter. ED stated that for an observer, this might seem like a visitor is coming in without being screened but that is not the case. Any visitor will be denied entry without being screened for COVID-19 symptoms and following screening protocols. Continued, see LIC 809-C, page 2 of 2.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys Kuizon	TELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2020

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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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: ATRIA WILLOW GLEN	FACILITY NUMBER: 435200605
	VISIT DATE: 11/20/2020

NARRATIVE

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For healthcare providers who bypass the main entrance and go directly to the Memory Care building, a designated staff conducts screening prior to allowing them to enter. The Memory Care building is locked and nobody can enter unless a staff opens the door.

2. Symptom checking: Facility is conducting symptom checking for residents and staff twice daily per SCCPHD recommendation. Kaiser Permanente (KP) has requested that KP residents' vitals be checked hourly. Facility has concerns regarding this request due to lack of qualified staff to check vitals. Facility had requested KP to provide a qualified medical professional to check KP residents' vitals hourly. Facility has not received response from KP regarding this request.

3. Trash bins: CDPH-Healthcare Associated Infections (HAI) Program team recommended that the facility obtain trash bins with lids and foot pedals instead of uncovered garbage cans. Facility has already completed this recommendation.

4. Communal dining: SCCPHD initially instructed the facility to discontinue communal dining in the Memory Care unit and the facility complied. However, when all COVID-19 test results came back indicating all residents are positive, communal dining was permitted by SCCPHD due to the whole unit being treated as a cohort at that point.

5. Hand hygiene: Due to the residents' needs and CCLD regulations in caring for residents with dementia, the facility is unable to have hand sanitizers accessible in the Memory Care unit. Facility provides personal hand sanitizers to every staff member. Additionally, hand sanitizing stations are permanently set up by the facility's main entrance and every building entrance. Hand washing sinks are equipped with hand soap and paper towels.

At time of meeting, written report from HAI visit containing Infection Control and Mitigation recommendations was not available for review. Facility was advised to continue following CCLD and SCCPHD recommendations until HAI report is received. A follow-up meeting will be scheduled once HAI recommendations are received.

This report was discussed with and provided to Executive Director Kurt Gursu via email for signature.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys Kuizon	TELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2020

LIC809 (FAS) - (06/04)

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