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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201549
Report Date: 06/17/2022
Date Signed: 06/17/2022 04:14:26 PM

Document Has Been Signed on 06/17/2022 04:14 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:CORKTREE HOUSEFACILITY NUMBER:
435201549
ADMINISTRATOR:CAYABYAB, PERLAFACILITY TYPE:
735
ADDRESS:2170 CORKTREE LANETELEPHONE:
(408) 499-3708
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY: 6CENSUS: 6DATE:
06/17/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:CAYABYAB, PERLATIME COMPLETED:
10:10 AM
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Licensing Program Analyst (LPA) Christine Dolores conducted a scheduled technical assistance visit and met with Administrator, Perla Cayabyab though a virtual platform, Zoom. During visit, LPA toured the facility virtually with the Administrator, Program Clinical Consultant (PCC) Lori Kopplinger and Licensing Program Manager (LPM) Romeo Manzano. The purpose of the visit was to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility.

During today's tele-visit, the following recommendations were made to the facility:

1. Remove the "No visitors" sign at the main entrance and to review the most recent PIN on visitation.
2. The re-use of gowns are not recommended.
3. Train staff on PPE use every 6 months and ensure to document the training. Encourage staff to reference the donning and doffing sign when using PPE.
4. Use a dispenser or holder for the paper towels located in the bathrooms.
5. When providing laundry services to the COVID positive residents, wash laundry using the highest temperature for 20 minutes to get rid of the virus. After the load of laundry, wipe down the washing machine.
6. Follow the disinfectant manufacturing instructions and check if they are EPA approved.

No deficiencies were cited as per California Code of Regulations, Title 22. This report was reviewed via telephone with Administrator and a copy of the report will be emailed for signature.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2022
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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