<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202191
Report Date: 04/07/2022
Date Signed: 04/11/2022 06:48:02 PM

Document Has Been Signed on 04/11/2022 06:48 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:NEWLIFE CARE SERVICES, INC. DBA NEWLIFE RCHFACILITY NUMBER:
435202191
ADMINISTRATOR:AMALIA AGUASFACILITY TYPE:
735
ADDRESS:4425 ADRAGNA COURTTELEPHONE:
(408) 832-3021
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 6CENSUS: 6DATE:
04/07/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Rico AguasTIME COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Steve Chang, Licensing Program Manager (LPM) Romeo Manzano, and Program Clinical Consultant (PCC) Helen Shi conducted Technical Assistant through tele-inspection (Zoom), and met with Administrator (ADM) Rico Aguas.

The purpose of this Technical Assistance (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. It was observed that the facility did not have a signage about "face mask" on the main door and in inside the facility. The facility garage is being used for staff and/or visitors for donning PPE. During inspection of garage, the facility did not have a signage on the proper donning and doffing sequence of PPE and there was no sanitizers observed. Facility has a screening station with infection control questionnaires, visit log book, thermometer, and hand sanitizers before entering the facility living room.

The facility common areas were inspected such as the kitchen, living room, family room, bedrooms, dinning area, laundry room and bathrooms. Trash cans were observed with covers in bathrooms and kitchen. Hand cloth towel was observed in the kitchen (hanging on stove handle). PCC and LPM informed licensee about cross-contamination to ensure that staff does not share a common hand towel in the kitchen and bathrooms.

Based on today's inspection, the facility is being recommended the following:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: NEWLIFE CARE SERVICES, INC. DBA NEWLIFE RCH
FACILITY NUMBER: 435202191
VISIT DATE: 04/07/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
1. Facility to post "face mask" signage on the facility main door and inside the facility.
2. Facility staff to wear full PPE.
3. Facility to place a hand sanitizer in garage, and post the sequence of donning and
doffing PPEs.
4. Facility to have paper towels with dispenser or with holders in kitchen and in restrooms.
5. Facility to disinfect high touch areas more often.
6. Facility to update COVID infection control questionnaires.
7. Facility to conduct staff training at least monthly or 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.
8. Facility use of N95 mask by staff must have completed a N95 mask fitting test
conducted by medical professional per CalOSHA.
9. Facility to have separate laundry basket for each resident, and clean/disinfect each
laundry basket after laundry.
10. Facility to have one main entrance for visitors to enter facility and have one exit door to
leave facility.
11. Facility to reorganize garage to separate laundry area and the area for donning PPE.
12. Facility to plan and develop an isolation room to include signage on the door and PPE
cart outside of the isolation room.
13. Facility to have a trash can with cover at the exit door to throw the PPE when leaving
facility.
14. LPA provided COVID-19 resource to Licensee.

No deficiencies cited during today's Tele Visit. Exit interview conducted with ADM.
A copy of this report emailed to ADM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2