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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202159
Report Date: 12/04/2020
Date Signed: 12/08/2020 09:12:55 AM

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:MERRILL GARDENS AT WILLOW GLENFACILITY NUMBER:
435202159
ADMINISTRATOR:GRACE KOMASAKAFACILITY TYPE:
740
ADDRESS:1420 CURCI DRTELEPHONE:
(408) 283-0941
CITY:SAN JOSESTATE: CAZIP CODE:
95126
CAPACITY:150CENSUS: 70DATE:
12/04/2020
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Grace KomasakaTIME COMPLETED:
02:27 PM
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Due to COVID-19 pandemic, Licensing Program Analysts (LPAs) Yatfai Eric Ng and Jackie Jin, partnered with a Health Facilities Evaluator Nurse (HFEN) Sheryll D. Falcone from the California Department of Public Health, conducted a Case Management - Other - tele-visit via FaceTime, to provide a technical assistance to prevent and mitigate the spread of COVID-19 at the facility. LPAs and HFEN met with the General Manager (GM) Grace Komasaka. LPAs and HFEN toured the facility virtually with GM holding the telephone to show around the facility. The tour started at the entrance of the building. There was a screening station that required visitors to sign in and to fill out the questionnaire before proceeding. Hand sanitizing stations were scattered in the facility. COVID-19 posters were visible throughout the facility. Staff in the facility wore PPE. The dining room was not opened, residents' meals were delivered to their rooms. Common restrooms had soap and paper towels readily available. A covered trash bin was available inside the isolation room.

The following COVID-19 mitigation and infection control practices to prevent, contain, and mitigate the spread of COVID-19:
  1. 1 chair per table in the staff break room. Tables and chairs should be 6 feet apart.
  2. 2 staff were observed having their break in the resident dining area. They were not practicing social distancing. It is highly recommended to encourage staff to practice social distancing at all times even during break time.
  3. Post signs in highly visible locations (e.g., at entrances, in restrooms, staff break room/area) that promote everyday protective measures and describe how to stop the spread of germs by properly washing hands and properly wearing a mask and social distancing. (PIN 20-07 ASC- sample signage). CDC guidelines. PIN 20-38 ASC, PIN 20-23 ASC, PIN 20-19 ASC.
  4. Long benches at the game room were recommended to block off sections of the long bench to space people at least 6 feet apart.

GM stated the recommendations would be implemented. No deficiency cited during visit. This report was emailed to the RSD to review and to obtain a signature.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2020
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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