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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202092
Report Date: 06/01/2022
Date Signed: 06/01/2022 03:59:00 PM

Document Has Been Signed on 06/01/2022 03:59 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:THELMA'S HOMEFACILITY NUMBER:
435202092
ADMINISTRATOR:THELMA B. RUIZFACILITY TYPE:
735
ADDRESS:1164 CAMANO CT.TELEPHONE:
(408) 292-6631
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY: 6CENSUS: 5DATE:
06/01/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Elenita GanoTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Steve Chang, and Program Clinical Consultant (PCC) Roxane Fangon conducted Technical Assistant - PCC through tele-inspection (Zoom), and met with House Manager (HM) Elenita Gano.

The purpose of this TA PCC Tele visit was to review the facility COVID-19 infection mitigation plan and conducted inspection of the facility to ensure plan is being carried out and to provide support and guidance to 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 the COVID-19 posters at the main entrance. Screening station with screening questionnaire, hand sanitizer, thermometer, glove, and a visitor log was observed at the main entrance.

The facility common areas were inspected such as the kitchen, living room, dinning area, bathrooms, and laundry area. There are 5 resident bedrooms, and 2 bathrooms at facility. Trash cans were observed with covers. Paper towels were observed with holders. The laundry room was inspected. Washing hand for 20 seconds posters were observed by the sink in kitchen and restrooms. Resident rooms were inspected. PPE supplies were observed sufficient. HM 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: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/01/2022
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: THELMA'S HOME
FACILITY NUMBER: 435202092
VISIT DATE: 06/01/2022
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1. Facility to use disposable dishes and utensils for positive residents.
2. Facility to have N95 fitting test for staff who are caring for positive residents.
3. Facility to conduct staff training at least quarterly or as frequently as needed on
donning and doffing of PPE, COVID -19 updates by CDC, and/or local public
health and to review DSS-CCLD Providers Information Notice (PIN).
4. Facility to disinfect the high touched areas based on manufacture’s instruction on disinfection.
5. Facility to disinfect the high touched areas more often.
6. Facility to use the highest temperature for positive residents’ laundry.
7. Staff should be wearing N95 during this outbreak.
8. PIN information: https://www.cdss.ca.gov/inforesources/community-care-licensing/policy/provider-information-notices/adult-senior-care.
9. Facility to use disposable dishes and utensils for positive residents.


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

DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
LIC809 (FAS) - (06/04)
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