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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201557
Report Date: 02/05/2021
Date Signed: 02/05/2021 04:59:15 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:
02/05/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:33 PM
MET WITH:Leilani CortesTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Joanne Roadilla 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 spoke with Licensee Leilani Cortes.

On 1/27/21, the Department received a death report for a resident (R1) who passed away at the facility on 1/26/21. The purpose of the call was to obtain additional information. Licensee confirmed R1 was not under hospice care, R1 did not complain of any pain and staff only noticed that R1 was agitated for a few days. Licensee reported that R1 had a doctor's appointment on 1/25/21 and was prescribed medication. On 1/26/21, staff found R1 unresponsive and called 911. Resident's family member and medical team arrived who declared R1's death.

LPA requested copies of resident's records. Additional information may be required to complete the Case Management investigation.

No deficiencies cited during today's tele-visit. This report was reviewed with Leilani Cortes and a copy forwarded via email for review and signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne RoadillaTELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2021
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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