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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201557
Report Date: 09/22/2022
Date Signed: 09/22/2022 11:46:35 AM


Document Has Been Signed on 09/22/2022 11:46 AM - 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: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: 6DATE:
09/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Rosalia CalungcaginTIME COMPLETED:
11:55 AM
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Licensing Program Analysts (LPAs) Christine Dolores and Simi Rai arrived unannounced to conduct the facility's annual inspection focusing on infection control. LPAs met with lead caregiver, Rosalia "Rose" Calungcagin.

During visit, LPAs toured the facility to include the living room, kitchen, resident rooms, bathrooms, garage, and backyard. All exit routes were free and clear of obstruction. Swimming pool observed fenced and locked. Facility temperature maintained at 71 degrees Fahrenheit.

Staff present are fingerprint cleared and associated to the facility. All staff observed wearing a face mask. N95 fit testing conducted by the Administrator.

Facility has a central entry point for symptom screening and temperature check for all visitors. LPA Dolores advised to create a symptom screening log for all staff prior to starting their shift. Hand sanitizer made available. Bathrooms supplied with hand washing sign, paper supplies, and hygiene products. LPAs observed facility's Personal Protective Equipment (PPE) supplies. Facility has a designated visitation area and visitation procedures. Facility staff are trained on infection control. LPA reviewed the facility's procedures to isolation and monitoring for symptoms and temperature. The following posters observed to include required mask, COVID-19 precautions, symptoms of COVID, and visitation procedures.

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

This report was reviewed with Rosalia "Rose" Calungcagin and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022
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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