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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200605
Report Date: 11/13/2020
Date Signed: 12/01/2020 03:37:49 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 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: 48DATE:
11/13/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Kurt GursuTIME COMPLETED:
12:00 PM
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LPA Steve Nguyen, LPM Romeo Manzano, CDPH Health Facilities Evaluator Nurse (HFEN) Rebekha Bird-Wolgemuth, HAI IKennedy, and PHN Melissa Schilling conducted a tele-visit with Executive Director, Kurt Gursu and Memory Care Director, Richard Olsen. The tele-visit consisted of a virtual tour of the facility and LPA advised Kurt the purpose of the visit was to provide the facility guidance and assistance regarding COVID-19 positive status of facility.

The tour showed that the facility (main building) had sufficient COVID-19 signage throughout the facility. Restroom were observed clean and with paper towels. Hand sanitizing station were available throughout the facility. Observed sign in forms and temperature check (with digital thermometer) station at front entrance (main building). Additionally, the facility had ample PPE's on hand and mitigation/ infection control has been submitted to CCLD. All staff were observed wearing face masks. LPA observed house keepers cleaning facility while conducting virtual tour. House keepers are using EPA approved disinfectant and all chemicals are locked away while not in use. Food was observed to be served in disposable containers. Staff encourages residents to social distance.

The facility has 3 shifts:

There are no staffing issues at this time

AM has 4 staff, 1 med tech, 1 director, and 1 activity staff
PM has 3 staff, 1 med tech, 1 director, and 1 activity staff
NOC has 1 staff, 1 med tech

SUPERVISOR'S NAME: George NwaforTELEPHONE: (408) 324-2116
LICENSING EVALUATOR NAME: Steve NguyenTELEPHONE: (650) 676-0051
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 11/13/2020
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Per Administrator, facility has designated staff to work in memory care unit.

Based on observations, the following recommendations were made:
1. Place covered trash can inside each isolation room and outside
2. Provide paper towel dispenser in restroom
3. Staff should shower and change before entering their residences
4. Positive Covid residents should cohort during meal service
5. Negative Covid residents should be separated from COVID positive residents during meals

Reviewed report with Kurt Gursu and an email sent for signature purposes.

END OF REPORT
SUPERVISOR'S NAME: George NwaforTELEPHONE: (408) 324-2116
LICENSING EVALUATOR NAME: Steve NguyenTELEPHONE: (650) 676-0051
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020
LIC809 (FAS) - (06/04)
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