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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200964
Report Date: 10/07/2022
Date Signed: 10/07/2022 04:33:51 PM

Document Has Been Signed on 10/07/2022 04:33 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:MERTZ CARE HOME IVFACILITY NUMBER:
435200964
ADMINISTRATOR:MERTZ, ELVIRAFACILITY TYPE:
735
ADDRESS:2591 BOREN DRIVETELEPHONE:
(408) 947-0825
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 6DATE:
10/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Jonysus Tabuli TIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection focusing on infection control. LPA and met with Designee Administrator, Jonysus Tabula.

During visit, LPA toured the facility to include the resident rooms, bathroom, living room, kitchen, garage, and backyard. Medications, sharp objects, and toxins observed secured.
Facility has a designated entry point for symptom screening and temperature check for all visitors, residents, and staff. Hand sanitizer made available at entry. LPA advised to remove the no visitor sign at the front door. Bathroom was under construction during visit. Designee Administrator states to post the hand washing sign, paper supplies, and hygiene products after construction. LPA observed the facility's Personal Protective Equipment (PPE) supplies. LPA observed the resident's emergency contact information / face sheets. LPA advised for all staff to be trained on infection control. Staff are not N95 fit tested. The following posters observed to include symptoms of COVID, social distancing, and droplet precaution. LPA reviewed facility's procedures to visitation, infection control training, isolation, and testing for COVID-19. Facility monitor the resident's COVID-19 testing on a weekly basis.

The following documents obtained during visit to include the LIC610D and LIC308.

No deficiencies were cited per California Code of Regulations, Title 22. Advisory notes provided.

This report was reviewed with the Designee Administrator, Jonysus Tabula and Roel Yusico and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2022
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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