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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200605
Report Date: 12/09/2020
Date Signed: 12/10/2020 12:11:18 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: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: 44DATE:
12/09/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Kurt GursuTIME COMPLETED:
11:45 AM
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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) to collaborate with the facility and ensure concerns regarding COVID-19 Infection Control and Mitigation procedures are addressed.

Community Care Licensing Division (CCLD) Licensing Program Analyst (LPA) Gladys Kuizon, CDPH Health Facilities Evaluator Nurse (HFEN) Rebekah Bird-Wohlgemuth, CCLD Regional Manager (RM) and facility's Executive Director (ED) Kurt Gursu (Executive Director) attended the conference call.

The following were discussed today:
1. Outdoor donning and doffing tent: The facility's Memory Care building has completed its isolation period. At this time there are no active positive cases in the building. Thus, facility staff are no longer required to don and doff isolation gowns prior to entering and exiting the Memory Care building. Per today's discussion, the outdoor donning and doffing tent outdoors may be removed. Facility may move the screening area inside the building.

2. PPE use: Facility staff may use KN95 masks instead of N95 masks at this time, This only continues to apply so long as there is no active positive case that staff is caring for.

3. COVID+ resident returning from doctor's visit/hospital: Clarification from SCCPHD Nurse Schilling was received today that resident who has previously been identified as COVID+ and is returning from a doctor's visit or hospitalization does not need to complete another 14-day isolation/quarantine period.

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: 12/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2020
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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