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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202171
Report Date: 10/14/2022
Date Signed: 10/18/2022 02:23:01 PM

Document Has Been Signed on 10/18/2022 02:23 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:TERRA COTTA HOMEFACILITY NUMBER:
435202171
ADMINISTRATOR:ANGELINA DOOLABHFACILITY TYPE:
735
ADDRESS:3233 TERRA COTTA DR.TELEPHONE:
(408) 270-7440
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY: 6CENSUS: 6DATE:
10/14/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Manharlal DoolabhTIME COMPLETED:
11:10 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 House Manager (HM) Manharlal Doolabh.

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, dinning area, and bathrooms. Posters of washing hands for 20 seconds were observed by the sinks in the restrooms and kitchen. Most of trash cans were observed with covers. A few trash cans were observed without covers. It is recommended to have trash cans with cover and foot pedal. No paper towel were observed in kitchen. Some paper towels were observed without the holders. ADM stated the facility will put the paper towels with holders in facility. There are 2 single resident bedrooms and 2 resident shared bedrooms in facility. It is recommended that all the staff wear N95 masks since all the residents are positive. One visitor with mask was observed at the backyard.

HM stated all the residents and staff are fully vaccinated and done with boosters.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2022
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: TERRA COTTA HOME
FACILITY NUMBER: 435202171
VISIT DATE: 10/14/2022
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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 have paper towel available in the kitchen.
3. Facility to have all the trash cans with covers.
4. 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.
5. It recommended that staff wear N95 masks in facility since all residents are positive.
6. 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.
7. Facility to review the Infection Control Plan.
8. It is recommended to use disinfectant to wipe the high touch areas frequently.

No citation was 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: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022
LIC809 (FAS) - (06/04)
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