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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202117
Report Date: 02/02/2022
Date Signed: 02/02/2022 04:39:16 PM

Document Has Been Signed on 02/02/2022 04:39 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:SILVER STAR RESIDENTIAL CARE HOMEFACILITY NUMBER:
435202117
ADMINISTRATOR:FE.O.PUNZALANFACILITY TYPE:
735
ADDRESS:5130 SAN FELIPE RD.TELEPHONE:
(408) 270-6005
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY: 6CENSUS: 6DATE:
02/02/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Fe PunzalanTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) David Marrufo, Licensing Program Manager Sarah Yip, and Nurse Toni Rivera conducted a tele-visit via Zoom to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility and met with Administrator Fe Punzalan.

Administrator Fe Punzalan reports that there are currently 0 COVID-19 positive residents and 0 COVID-19 positive staff.

During today's tele-visit, the following recommendations were made to the facility by Nurse Toni Rivera:

1. Use the right ratios of cleaning solutions and make a new batch every 24 hours
2. Conduct resident temperature checks 3 times a day
3. Modify Mitigation Plan to include serving meals inside of isolation rooms to COVID-19 positive residents
4. Launder COVID-19 negative residents' laundry first, then positive residents' laundry; staff should wear PPE while laundering COVID-19 positive residents' clothing and garments.
5. Include a plan to isolate positive residents in bedrooms and move negative residents to other rooms in the facility to use as bedrooms if necessary to the facility Mitigation Plan.

No deficiencies were cited as per California Code of Regulations, Title 22.

This report was reviewed with with Fe Punzalan. A copy of the report will be sent to her for to be signed and returned to CCL.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2022
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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