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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202377
Report Date: 01/07/2021
Date Signed: 01/08/2021 03:49:25 PM

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:FAMILY SENIOR CARE HOME, LLCFACILITY NUMBER:
435202377
ADMINISTRATOR:ELIZABETH D. BAUTISTAFACILITY TYPE:
740
ADDRESS:5343 HANSELL DRIVETELEPHONE:
(408) 362-9195
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:6CENSUS: 5DATE:
01/07/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Elizabeth BautistaTIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Gladys Kuizon conducted a Technical Assistance tele-visit today with CA Department of Public Health (CDPH) Health Facilities Evaluator Nurse (HFEN) Rebekah Bird-Wohlgemuth, RN.

Present during the tele-visit were Administrator Elizabeth Bautista, Santa Clara County Public Health (SCCPH) representatives Joseph Odias and Michelle Cha, Community Care Licensing Division Assistant Program Administrator Stacy Barlow, Regional Manager Vivien Helbling, and Licensing Program Manager Romeo Manzano.

The facility currently has a census of 5. 2 out of 5 residents are currently transferred to a hospital. 1 out of 3 residents in the facility is isolating in a private room. Staff were observed wearing N-95 masks. The isolation room door was observed closed and marked with isolation room signs. A personal protective equipment (PPE) station was observed outside the isolation room and equipped with hand sanitizer, gloves, masks, and isolation gowns.

Per Administrator, the facility has sufficient staffing for the 3 residents in the facility. Facility was able to hire an additional staff through a licensed home care organization.

Based on facility tour, the following recommendations were provided:

1. Facility shall utilize a written screening questionnaire with current COVID-19 symptoms in their entrance screening procedure. Please refer to www.cdc.gov.

Continued, please see LIC 809-C, page 2 of 2.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2021
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: FAMILY SENIOR CARE HOME, LLC
FACILITY NUMBER: 435202377
VISIT DATE: 01/07/2021
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2. SCCPH discourages communal dining at this time. Facility may resume communal dining after COVID-19 clearance from SCCPH.
.
3. Facility shall use covered trash bins. A trash bin with sensors or a foot pedal is highly recommended to minimize the touching of surfaces.

4. Facility shall post PPE donning and doffing sequence diagram where staff is expected to don and doff PPE.

5. Per Administrator, each staff uses 1 isolation gown per shift. HFEN recommends that used isolation gowns intended for re-use be hang separately and not touching each other. A system must be in place to ensure staff are not using another staff member's isolation gown. All used gowns must be discarded after every shift.

6. Unused PPE shall be stored in a manner that prevents it from contamination. Facility to ensure PPE supply is not exposed to contaminants unnecessarily (i.e. unused gown removed from packaging and hung on a door, box of gloves stored by hand-washing sink and prone to getting wet)

7. Posters on proper hand-washing techniques shall be placed on all hand-washing stations.

SCCPHD recommends mass testing of all negative staff and residents every 3 days. Mass testing to cease after 2 consecutive negative results of mass testing. Per Administrator, a mass testing is scheduled on January 8, 2021.

Facility to submit the following to Community Care Licensing Division by January 24, 2021:

1. Update COVID-19 Mitigation Plan in accordance with Provider Information Notice (PIN) 20-48-ASC.

2. Current LIC 500 - Personnel Schedule

This report was discussed with and a copy provided to Administrator Elizabeth Bautista via email for signature.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2021
LIC809 (FAS) - (06/04)
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