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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201809
Report Date: 07/11/2022
Date Signed: 07/18/2022 08:52:29 AM

Document Has Been Signed on 07/18/2022 08:52 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:BLUE SKY RESIDENTIAL CARE HOMEFACILITY NUMBER:
435201809
ADMINISTRATOR:RFACILITY TYPE:
735
ADDRESS:4040 BRIARGLEN DR.TELEPHONE:
(408) 314-3253
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY: 6CENSUS: 6DATE:
07/11/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Victoria AlejandroTIME COMPLETED:
10:50 AM
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Licensing Program Analyst (LPA) Steve Chang, Licensing Program Manager (LPM) Romeo Manzano and Program Clinical Consultant (PCC) Lori Kopplinger conducted Technical Assistant - PCC through tele-inspection (Zoom), and met with Administrator (ADM) Victoria Alejandro.

The purpose of this TA Tele visit was to review the facility COVID-19 infection mitigation plan and facility inspection of physical plant to ensure plan is being carried out, and to provide support and guidance to the staff in mitigating the spread of virus.

During tele-visit inspection, a tour of the facility was conducted which started at the main entrance to check COVID-19 signage and screening procedures. The facility has COVID-19 signage at the main entrance door, and screening station with the following: screening questionnaire, hand sanitizer, thermometer, face masks, and a visitor log. The infection prevention/control questionnaires were observed too old. LPA sent the updated document to LPA after the touring of the facility.

The facility common areas were inspected such as the kitchen, living room, family room, dinning area, and bathrooms. Cloth towels were observed in kitchen. The trash cans in kitchen was observed without covers. There are washing hands signage with washing hands for 20 seconds by the sink in kitchen and restrooms. Paper towels were observed with holders. Four resident bedrooms were observed and inspected. Beds were observed 6 feet apart in resident shared rooms. Laundry area was observed and inspected. Cloth towels were observed on the washing machine and dryer machine. ADM stated all the residents and staff are fully vaccinated and done with booster.

Based on today's inspection, below are the recommendations:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: BLUE SKY RESIDENTIAL CARE HOME
FACILITY NUMBER: 435201809
VISIT DATE: 07/11/2022
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1. Facility to update the infection prevention/control questionnaires.
2. Facility to remove the cloth towels in kitchen.
3. Facility to have trash can with cover in kitchen.
4. Facility to remove the cloth towels in laundry area.
5. Facility to have staff to do the N95 fitting test.
6. Facility to post signage of donning and doffing PPE.
7. Facility to wash the COVID negative first and last the COVID positive for laundry.
8. Facility to frequent wipe down common/ high touch areas with EPA grade disinfectants.
10. LPA provide extra information in another email.
11. Face shield can be use one time only.
12. PIN information: https://www.cdss.ca.gov/inforesources/community-care-licensing/policy/provider-information-notices/adult-senior-care.

No deficiencies cited during today's Tele Visit. Exit interview conducted with ADM.
A copy of this report emailed to ADM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022
LIC809 (FAS) - (06/04)
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