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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202281
Report Date: 06/27/2022
Date Signed: 06/29/2022 08:01:05 AM

Document Has Been Signed on 06/29/2022 08:01 AM - 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:ROSARIO HOME LLCFACILITY NUMBER:
435202281
ADMINISTRATOR:ELVIRA CASIMFACILITY TYPE:
735
ADDRESS:2843 ROSARIO DRIVETELEPHONE:
(408) 802-9105
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY: 6CENSUS: 5DATE:
06/27/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Shujen ColladoTIME COMPLETED:
09:50 AM
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Licensing Program Analyst (LPA) Steve Chang, Licensing Program Manager (LPM) Romeo Manzano and Program Clinical Consultant (PCC) Lori Kopplinger conducted Technical Assistant - PCC through tele-inspection (Zoom), and met with Lead staff Shujen Collado. (SC)

The purpose of this TA Tele visit was to review the facility COVID-19 infection mitigation plan and facility inspection of physical plant to ensure plan is being carried out, and to provide support and guidance to the staff in mitigating the spread of virus. Today's PCC tele visit is the second PCC tele visit to follow up for the first PCC tele visit.

During tele-visit inspection, a tour of the facility was conducted which started at the main entrance to check COVID signage and screening procedures. There were COVID signage observed by the main door. The screening station was observed by the main door including visitor log, infection control/prevention questionnaires, thermometer, hand sanitizer, masks, and paper towels.

The facility common areas were inspected such as the kitchen, living room, dinning area, and bathrooms.
Trash cans were observed with covers except the one under the sink, inside the closed, in the kitchen. Paper towels were observed holders. Washing hands signage were observed by the sink in kitchen and restrooms. Three resident bedrooms were observed and inspected. The beds in the shared bedrooms were observed less than 6 feet apart. Laundry area were observed and inspected. The refrigerator in laundry area were observed away from the laundry baskets and away from drier machine. SC stated all the positive cases are tested negative now.

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: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2022
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: ROSARIO HOME LLC
FACILITY NUMBER: 435202281
VISIT DATE: 06/27/2022
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1. Facility to frequent wipe down common/ high touch areas with EPA grade disinfectants.
2. Facility to have N95 fitting test for staff.
3. PIN information: https://www.cdss.ca.gov/inforesources/community-care-licensing/policy/provider-information-notices/adult-senior-care.
4. Facility to conduct staff training at least monthly or frequently such as donning and doffing PPE and COVID -19 updates.
5. The beds in shared rooms should either keep 6 feet apart or change the orientation of the beds.
6. facility to have washing hands for 20 seconds signage by the sinks.

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

DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022
LIC809 (FAS) - (06/04)
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