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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202172
Report Date: 03/22/2022
Date Signed: 03/22/2022 02:22:23 PM

Document Has Been Signed on 03/22/2022 02:22 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,
, CA
FACILITY NAME:STURLA CARE HOMEFACILITY NUMBER:
435202172
ADMINISTRATOR:DUMANTAY, MARJORIEFACILITY TYPE:
735
ADDRESS:2644 STURLA DRTELEPHONE:
(408) 818-0134
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 3DATE:
03/22/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Marjorie DumantayTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted a Technical Assist (TA) Visit via FaceTime with Marjorie Dumantay Administrator and Sarah Yip Licensing Program Manager to provide technical assistance to prevent and mitigate the spread of COVID 19 in the facility. LPA conducted a virtual tour of the facility.

During today's TA-Visit, recommendations were discussed as follows:

1. Use written COVID 19 Screening Questionnaire for visitors and staff
2. Use paper towels instead of cloth towels
3. Post hand washing signs in the bathrooms
4. Secure toxins and disinfectants after use
5. Post Donning and Doffing PPEs signs outside and inside Isolation room
6. Review OSHA N95 Fit Test Requirements for staff working with COVID 19 Positive residents

LPA will forward updated COVID Screening Questionnaire and N95 FIT Testing Information.

Report reviewed with Marjorie Dumantay and a copy emailed for signature.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Marybeth Donovan
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2022
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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