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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200751
Report Date: 02/03/2022
Date Signed: 02/03/2022 04:54:38 PM

Document Has Been Signed on 02/03/2022 04:54 PM - It Cannot Be Edited

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:MUNA'S RESIDENTIAL CARE HOME IFACILITY NUMBER:
435200751
ADMINISTRATOR:EMAD QADDURAFACILITY TYPE:
735
ADDRESS:4232 INDIGO DR.TELEPHONE:
(408) 979-9265
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 6CENSUS: 6DATE:
02/03/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:EMAD QADDURATIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Steve Chang, and Program Clinical Consultant (PCC) Roxane Fangon conducted Technical Assistant - PCC through tele-inspection (Zoom),and met with Administrator (ADM) Emad Qaddura.

The purpose of this TA PCC Tele visit was to review the facility COVID-19 infection mitigation plan and conducted inspection of the facility to ensure plan is being carried out and to provide support and guidance to staff in mitigating the spread of virus.

During tele-visit inspection, a tour of the facility was conducted which started at the main entrance to check COVID-19 signage and screening procedures. The facility has the COVID-19 posters at the main entrance including screening questionnaire forms, hand sanitizer, face masks, thermometer, glove, and a visitor log book at the screening station.

The facility common areas were inspected such as the kitchen, living room, family room, dinning area, laundry room, and bathrooms were observed. There are 3 resident bedrooms, 2 bathrooms in facility. Some trash cans were observed without covers. Some paper towels were observed without holders. Washing hands signs by the sinks were observed. Cloth towels were observed in the restrooms and kitchen. The laundry room was observed and inspected. ADM stated all the residents and staff are fully vaccinated with Pfizer and done with booster shots with Pfizer.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2022
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: MUNA'S RESIDENTIAL CARE HOME I
FACILITY NUMBER: 435200751
VISIT DATE: 02/03/2022
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Based on today's inspection, the facility is being recommended the following:

1. Facility to frequently wipe and disinfect high touch areas, it is recommend to use EPA approve (Environmental Protection Agency) disinfection products.
2. Facility to have covered Trash cans with foot pedal in facility.
3. Remove the Kitchen cloth towels.
4. Do not leave any cloth towel in restrooms.
5. Paper towels should be with holders.
6. If the beds in shared rooms cannot keep 6 feet apart, change the head orientation of the beds.
7. Monitoring residents and staff for symptoms and change of condition and contact PCP immediately.
8. No need to do testing for 90 days; however; if symptoms occur, do PCR test.
9.. Do the laundry for negative residents first, then do the laundry for the positive residents.
10. Use high temperature hot water for laundry.
11. N95 Seal check reference:
https://www.cdc.gov/niosh/docs/2018-130/pdfs/2018-130.pdf
https://www.youtube.com/watch?v=oU4stQgCtV8
12. Facility to review PINs (Providers’ Information Notification) through CCLD website: www.ccld.ca.gov


No deficiencies cited during today's Tele Visit. Exit interview conducted with Administrator.
A copy of this report emailed to ADM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
LIC809 (FAS) - (06/04)
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