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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201781
Report Date: 09/23/2021
Date Signed: 09/30/2021 09:52:22 AM

Document Has Been Signed on 09/30/2021 09:52 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:NANTUCKET HOME 2FACILITY NUMBER:
435201781
ADMINISTRATOR:CRISTOBAL, MARIAFACILITY TYPE:
735
ADDRESS:2055 ADMIRAL PLACETELEPHONE:
(408) 347-1744
CITY:SAN JOSESTATE: CAZIP CODE:
95133
CAPACITY: 6CENSUS: 3DATE:
09/23/2021
TYPE OF VISIT:Case Management - COVID-19ANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Maria CristobalTIME COMPLETED:
11:25 AM
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Due to COVID-19 pandemic, Licensing Program (LPM) Manager Romeo Manzano and Licensing Program Analyst (LPA) Yatfai Eric Ng partnered with Program Clinical Consultant (PCC) Paul Portem from the Department, conducted a tele-Case Management - COVID-19 via FaceTime, to provide a technical assistance to prevent and mitigate the spread of COVID-19 at the facility. LPM, LPA, and PCC met with the Administrator Maria Cristobal.

The virtual tour started at the outside of the entrance of the facility. There were precaution signs of COVID-19. Inside, LPA observed there was a screening station that had hand sanitizer, thermometer, visitor log, and temperature logs to screen the visitors and staff. There were more signs throughout the facility to remind everyone masking and social distancing. Staff in the facility wore masks at all time. Restrooms had soap, paper towels, and trash bins with lids readily available. 1 restroom had hand washing signs posted. Disinfection was performed at least 2 times a day, more as needed. Staff's hand washing practice was reviewed.

Following infection control practices were suggested to prevent and mitigate the spread of COVID-19:
  1. Put a CDC COVID-19 Screening Questionnaire at the entrance
  2. Remove the chairs in the dining room to ensure residents sit at least 6 feet apart
  3. Male staff should shave daily before putting on any mask
  4. Staff and residents (if possible) need to conduct N95 masks fit testing
  5. Check and follow the instruction of the disinfectant
  6. Remove towel in common area to avoid cross-contamination
  7. Post donning and doffing procedures with pictures for easier reading
  8. Provide visual aids and training about the proper ways of putting on masks

No deficiency cited during visit. This report was emailed to the Administrator to review and to obtain signature. LPA sent additional resource about mitigation of COVID-19 was sent to Administrator for reference.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Yatfai Ng
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2021
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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