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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200967
Report Date: 01/20/2021
Date Signed: 02/01/2021 11:57:32 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:ROSE GARDEN COURTFACILITY NUMBER:
435200967
ADMINISTRATOR:ROSETE, LILETTEFACILITY TYPE:
740
ADDRESS:958 VERMONT STREETTELEPHONE:
(408) 247-0815
CITY:SAN JOSESTATE: CAZIP CODE:
95126
CAPACITY:30CENSUS: 10DATE:
01/20/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
09:46 AM
MET WITH:Michael Rosete & Lilette RoseteTIME COMPLETED:
10:48 AM
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Due to COVID-19 pandemic, Licensing Program Manager (LPM) Sarah Yip and Licensing Program Analyst (LPA) Yatfai Eric Ng partnered with Health Facilities Evaluator Nurse (HFEN) Mira Belle Villamin from the California Department of Public Health, conducted a Case Management - Other - tele-visit via FaceTime, to provide a technical assistance to prevent and mitigate the spread of COVID-19 at the facility. LPM, LPA, and HFEN met with the Administrators (ADMs) Michael Rosete and Lilette Rosete. LPM, LPA, HFEN, and ADMs toured the facility virtually. The tour started at the outside of the entrance. There were precaution signs of COVID-19. A screening station and sign in sheet were observed at the entrance. Staff in the facility wore masks at all time. Common restrooms had soap, paper towels, and hand dryer. A PPE station with PPE supply was readily available. A hand sanitizer was added to the PPE supply.

The following infection control practices were recommended:
  1. Only maintain one entrance, other entrances should be locked. Post signs to remind staff and visitors to report to the main entrance
  2. PIN 20-38 ASC guidance should be posted at the entrance
  3. More signs should be posted throughout the facility to remind residents, staff, and visitors to practice social distancing and maintain good personal hygiene
  4. Isolation room sign, respiratory droplet precaution sign, etc. on the door of the isolation room
  5. Post PPE donning and doffing signs inside and outside of the isolation room
  6. Staff should be screened twice per shift
  7. Step-on trash bins with lids were recommended to replace open trash bins in the facility
  8. Rearrange chairs, tape off portions of sofas to increase distance in common area and staff break room
  9. Remove cloth towel in the staff restroom

ADMs stated the recommendations would be reviewed and implemented. No deficiency cited during visit. This report was emailed to the ADMs to review and to obtain signatures.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2021
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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