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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201737
Report Date: 02/11/2022
Date Signed: 02/11/2022 03:27:53 PM

Document Has Been Signed on 02/11/2022 03:27 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,
, CA
FACILITY NAME:HILLSIDE RANCH CORPORATIONFACILITY NUMBER:
435201737
ADMINISTRATOR:APOSTOL, OBEDFACILITY TYPE:
735
ADDRESS:2320 SHAFER AVENUETELEPHONE:
(408) 930-9872
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 6CENSUS: 6DATE:
02/11/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Obed ApostolTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted a Technical Assist (TA) Visit via Zoom platform with Obed Apostol Administrator, Lori Kopplinger RN,Program Clinical Consultant, and Jackie Jin Licensing Program Manager to provide technical assistance to prevent and mitigate the spread of COVID 19 in the facility. LPA conducted a virtual tour of the facility.

During today's TA-Visit, recommendations were discussed as follows:

1. Review PIN 22-07-ASC Dated 2/8/2022 to include Visitation Guidelines
2. Post Hand Washing signs in bathrooms and use paper towels instead of cloth towels
3. Use foot operated waste receptacles
4. Place PPE supply cart next to Isolation Room
5. Review OSHA N95 Fit Test Requirements for staff working with COVID 19 Positive residents
6. Conduct additional training on Donning and Doffing of PPEs
7. Use disinfectants with 2 minutes or less wet time
8. Set up Screening station outside or inside next to the entry door to include updated visitor log with COVID . screaming symptoms, hand sanitizer and thermometer.
9. Update resident log and staff log to include the update COVID 19 Screening Symptoms as well.
10. Review COVID 19 Mitigation Plan and update as warranted

Report reviewed with Obed Apostol Administrator and a copy emailed for signature.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Marybeth Donovan
LICENSING EVALUATOR SIGNATURE: DATE: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2022
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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