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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200941
Report Date: 11/19/2020
Date Signed: 01/04/2021 11:14:50 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:LINCOLN GLEN ASSISTED LIVING CENTERFACILITY NUMBER:
435200941
ADMINISTRATOR:DIANE ELDRIDGEFACILITY TYPE:
741
ADDRESS:2671 PLUMMER AVENUETELEPHONE:
(408) 267-4872
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:93CENSUS: 42DATE:
11/19/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Administrator Diane EldridgeTIME COMPLETED:
10:00 AM
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LPA Steve Nguyen, LPM Romeo Manzano, CDPH Health Facilities Evaluator Nurse (HFEN) Janet Hayes, conducted a tele-visit with Administrator Diane Eldridge. The tele-visit consisted of a virtual tour of the facility and LPA advised Diane the purpose of the visit was to provide the facility guidance and assistance regarding COVID-19 positive status of facility.

Observations made during tour: Signs were apparent and at conspicuous vantage point throughout facility, hand sanitizing stations were available, paper towels present in restrooms, covered bin observed outside isolation room, designated seating/ social distancing was in place and observed in living/ dinning room, sign in and screening protocol was inspected, laundry of positive resident stated to be washed separately from others, and facility is using EPA approved disinfectant. Per administrator, no staffing concerns at this time.

Based on observations, the following recommendations were made by DPH:

Yellow Zone guidelines recommend full PPE. This would include wearing N95 masks and face shields/ goggles. Gowns and gloves should be worn when entering a resident room, and discarding gowns and gloves upon exiting.

In the Yellow Zone, all residents should be self-isolating in their rooms.

While difficult with staffing, the one positive resident (red zone) should have a care giver who is not caring for anyone in the yellow or green zones.
SUPERVISOR'S NAME: George NwaforTELEPHONE: (408) 324-2116
LICENSING EVALUATOR NAME: Steve NguyenTELEPHONE: (650) 676-0051
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE:
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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