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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202124
Report Date: 09/22/2021
Date Signed: 09/22/2021 02:04:36 PM

Document Has Been Signed on 09/22/2021 02:04 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:BEYOND POTENTIAL LEARNING CENTERFACILITY NUMBER:
435202124
ADMINISTRATOR:CARMELA MAGPAYOFACILITY TYPE:
775
ADDRESS:1753 SOUTH MAIN STREETTELEPHONE:
(408) 438-0377
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY: 75CENSUS: 72DATE:
09/22/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Melissa RamosTIME COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Joanne Roadilla conducted a Technical Assistance (TA) tele-visit today via Teams Meeting with Program Clinical Consultant (PCC) Nurse Helen Shi, RN and Licensing Program Manager (LPM) Romeo Manzano. The purpose of the tele-visit was to provide guidelines for Infection Control and Prevention. Present during the tele-visit was administrator (ADM) Melissa Ramos and two staff.

The day program facility was toured virtually with ADM. Per ADM, there are 6 staff and no clients at the facility, all programs are currently being done virtually.

Based on facility tour and interview with ADM, the following recommendations were provided:
1. Place hand-washing sign next to the hand-washing station outside of the facility.
2. Designate a staff who will conduct symptom checking of other staff.
3. Post sign on sick room door to wear full PPE before entering the sick room.
4. Post proper PPE donning/doffing instructions on sick room door.
5. Conduct regular staff training for proper PPE donning/doffing.
6. Ensure all staff have completed N95 fit testing per Cal/OSHA.

Facility was provided with some reference materials for PPE use and PIN 21-10-ASC Fit Testing Resources.

No deficiencies issued per Title 22 of the California Code of Regulations. A copy of the report was provided to Melissa Ramos via e-mail for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Joanne Roadilla
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2021
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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