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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201557
Report Date: 02/04/2021
Date Signed: 02/05/2021 04:44:32 PM

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:PRUNERIDGE RESIDENTIAL CARE HOMEFACILITY NUMBER:
435201557
ADMINISTRATOR:CORTES, LEILANIFACILITY TYPE:
740
ADDRESS:3030 PRUNERIDGE AVENUETELEPHONE:
(408) 247-2771
CITY:SANTA CLARASTATE: CAZIP CODE:
95051
CAPACITY:6CENSUS: 4DATE:
02/04/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Leilani CortesTIME COMPLETED:
03:16 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joanne Roadilla and Licensing Program Manager Romeo Manzano conducted an unannounced Case Management tele-visit today. The Department has suspended on site visits due to COVID-19 shelter in place order by Governor Newsom. LPA/LPM spoke with Licensee Leilani Cortes.

At 2:03 PM, LPA and LPM conducted an initial intake Technical Assistance call with Licensee. Licensee reported that 2 staff had started showing symptoms on 1/25/21 and was sent home to quarantine. Both staff got tested on 1/27/21 and 1 staff tested positive on 1/28/21 and the other staff tested positive on 1/29/21. Licensee stated that these cases were not reported by telephone within 24 hours of occurrence and a written incident report was not provided.

A deficiency was cited today. Please see LIC 809-D. This report was discussed with licensee Leilani Cortes and a copy provided via email for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne RoadillaTELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2021
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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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: PRUNERIDGE RESIDENTIAL CARE HOME
FACILITY NUMBER: 435201557
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/05/2021
Section Cited

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87211 REPORTING REQUIREMENTS (a)(2)
Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents ...shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.
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This requirement was not met as evidenced by: Facility reported a COVID-19 outbreak to CCLD more than 24 hours after receiving confirmed positive test results. This posed an immediate risk to the health & safety of residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne RoadillaTELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2021
LIC809 (FAS) - (06/04)
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