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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200605
Report Date: 11/22/2020
Date Signed: 11/23/2020 10:50:05 AM

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 GLENFACILITY NUMBER:
435200605
ADMINISTRATOR:GURSU, UGUR (KURT)FACILITY TYPE:
740
ADDRESS:1660 GATON DRTELEPHONE:
(408) 266-1660
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:63CENSUS: 46DATE:
11/22/2020
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Kurt Gursu, Executive DirectorTIME COMPLETED:
01:42 PM
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The San Bruno Regional Office - San Jose Unit held a joint conference call today with the CA Department of Public Health (CDPH) and Santa Clara County Public Health Department (SCCPHD) 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, Licensing Program Analyst (LPA) Gladys Kuizon, CDPH Health Facilities Evaluator Nurse (HFEN) Rebekah Bird-Wohlgemuth and SCCPHD Nurse Melissa Schilling met with facility representatives Kurt Gursu (Executive Director), Jason Walthour (Regional Vice President), and Jen Johnson (National Director of Care Management).

The following were discussed today:

1. Communal dining: SCCPHD Nurse Schilling clarified that communal dining in the Memory Care Unit is permitted at this time due to the entire unit being treated as a COVID-19 cohort.
2. Daily Line List: CCLD provided facility with names of individuals involved in monitoring the facility and should receive the daily line list sent out by the facility.
3. Daily symptom checking: CDPH HFEN and SCCPHD clarified that temperature and oxygen level checks must be done twice daily for residents for COVID-19 monitoring. Blood pressure checks should be done, if medically necessary (e.g. prior to medication administration).

A copy of this report was provided to ED Gursu via email for signature.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2020
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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