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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202100
Report Date: 10/07/2022
Date Signed: 10/07/2022 03:23:24 PM

Document Has Been Signed on 10/07/2022 03:23 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:MASTEN CARE HOMEFACILITY NUMBER:
435202100
ADMINISTRATOR:JHANELLE GUICOFACILITY TYPE:
735
ADDRESS:375 FITZGERALD AVE.TELEPHONE:
(408) 846-8985
CITY:SAN MARTINSTATE: CAZIP CODE:
95046
CAPACITY: 6CENSUS: 5DATE:
10/07/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:JHANELLE GUICOTIME COMPLETED:
11:26 AM
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Licensing Program Analyst (LPA) Steve Chang, and Licensing Program Manager (LPM) Sarah Yip conducted a Technical Assistant through tele-inspection (Zoom), and met with Administrator (ADM) JHANELLE GUICO.

The purpose of this TA 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 COVID-19 posters at the main entrance door and screening station with had hand sanitizer, face masks, thermometer, questionnaires .and guest log book.

The facility common areas were inspected such as the kitchen, living room, family room, dinning area, and bathrooms. Posters of washing hands for 20 seconds were observed by the sinks in the restrooms and kitchen. Trash cans were suggested to have covers with foot pedal. One paper towel was observed without the holder in the restroom. ADM stated the facility will put the paper towel with holder today. One restroom was designated for the COVID positive residents, and another restroom was designated for the COVID negative. Wash cloth towels was observed in the kitchen. The resident bedrooms were inspected. One shared bedroom was observed for the two COVID negative residents. Two bedrooms were observed for the three COVID positive residents as isolation rooms. PPE supplies and trash cans were observed outside the isolation rooms. The laundry room was observed and inspected.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2022
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: MASTEN CARE HOME
FACILITY NUMBER: 435202100
VISIT DATE: 10/07/2022
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Based on today's inspection, the facility is being recommended the following:

1. Facility to make sure all the paper towels are with holders.
2. Facility to conduct staff training frequently such as donning and doffing PPE and COVID -19 updates by CDC, local public health and to review DSS-CCLD (Providers Information Notice-PINS). CCLD website: www.ccld.ca.gov.
3. Facility use of N95 mask by staff must have completed a N95 mask fitting test conducted by medical professional per CalOSHA. ADM stated facility Human Resources will be contacted regarding CalOSHA requirements.
4. Facility to ensure that dirty laundry for negative and positive residents are separated by washing negative residents first, then do the laundry for the positive residents.
5. Facility to ensure staff use high water temperature when washing laundry for COVID positive residents.
6. Facility to ensure to use laundry bag/trash bag and to tie the laundry bag/trash bag for the COVID positive resident clothing.
7. Facility to review their Infection Control Plan.
8. Facility to mount the paper towel or put in the dispenser in the restroom if the counter of the sink is too small.

No citation was noted 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: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
LIC809 (FAS) - (06/04)
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