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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202307
Report Date: 07/19/2022
Date Signed: 07/19/2022 11:05:11 AM

Document Has Been Signed on 07/19/2022 11:05 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:SIESTA VISTA HOMEFACILITY NUMBER:
435202307
ADMINISTRATOR:MARIA CECILIA CLARIDADFACILITY TYPE:
735
ADDRESS:15860 SIESTA VISTA DRIVETELEPHONE:
(408) 258-5518
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 6CENSUS: 6DATE:
07/19/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:CECILIA CLARIDADTIME COMPLETED:
10:00 AM
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Licensing Program Analysts (LPA) Christine Dolores conducted a scheduled technical assistance visit and met with Administrator, Cecilia Claridad. During visit, LPA conducted a Zoom tour of the facility with Program Clinical Consultant (PCC) Roxane Fangon and Licensing Program Manager (LPM) Romeo Manzano. The purpose of the visit was to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility.

During today's tele-visit, the following recommendations were made to the facility by PCC:

1. Post a sign at the entrance requiring face masks before entering in the facility
2. Move the screening area to another location at the entrance that is not on the sink to reduce contamination
3. Provide hand soap, paper towels, hand washing sign, and a trash can with lid next to all hand washing areas
4. Remove the tumblrs inside the designated bathroom used for the COVID positive resident. Ensure to wash/sanitize the tumblrs prior to placing them back in the bathroom after isolation period
5. Review the correct sequence of donning and doffing PPE
6. Review how to perform a N95 seal check until all staff are N95 fit-tested
7. Provide N95 fit testing for staff
8. Ensure to clean and disinfect common surface areas 3 times a day and as often as needed
9. After isolation period, ensure to clean and disinfect the facility. Aerate the facility for about 2 hours if weather permits. Wash the COVID positive resident's laundry/linens in the hottest setting

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with the Administrator via telephone and a copy of the report was emailed for signature.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2022
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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