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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201796
Report Date: 11/04/2021
Date Signed: 11/04/2021 03:55:38 PM

Document Has Been Signed on 11/04/2021 03:55 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:NUEVA VISTAFACILITY NUMBER:
435201796
ADMINISTRATOR:WEINSTEIN, MICHAELFACILITY TYPE:
735
ADDRESS:18225 HALE AVENUETELEPHONE:
(408) 465-8280
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 72CENSUS: 70DATE:
11/04/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Jorge MendezTIME COMPLETED:
04:30 PM
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Licensing Program Analysts (LPAs) Christine Dolores and Marybeth Donovan conducted an unannounced annual inspection to include infection control site visit and met with Jorge Mendez, Vice President.

LPAs toured the facility inside and out to include the entry, hallways, client room, bathrooms, dining room, multi-purpose room, and courtyard. All fire exit routes were free and clear of obstructions.

Facility observed to have designated entry point for COVID 19 symptom screening for resident, staff, and visitors. Bathrooms observed to be supplied with hygiene products. Hand sanitizer available to residents and visitors. LPAs observed supply of Personal Protective Equipment (PPE). The following posters were observed to include, social distancing and COVID-19 symptoms. All staff are N95 fit tested.

LPAs reviewed the facility policies and procedures to include screening, visitation, isolation, disinfecting, staffing, training, PPE supplies and social distancing.

LPA Dolores will provide additional COVID-19 posters to use throughout facility and common areas.

No citations were issued per the California Code of Regulations, Title 22.

This report with reviewed with Jorge Mendez, Vice President and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2021
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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