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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202492
Report Date: 09/30/2021
Date Signed: 09/30/2021 02:46:54 PM

Document Has Been Signed on 09/30/2021 02:46 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:DYSICO CARE HOME, ARFFACILITY NUMBER:
435202492
ADMINISTRATOR:JOSEPHINE DYSICOFACILITY TYPE:
735
ADDRESS:787 E. SAN CARLOS STREETTELEPHONE:
(408) 286-5364
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY: 6CENSUS: 6DATE:
09/30/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Angelica BonuanTIME COMPLETED:
02:45 PM
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Licensing Program Manager (LPM) Jackie Jin, Licensing Program Analyst (LPA) David Marrufo, and Nurse Cristina Wong conducted a tele-visit via Zoom to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility and met with Angelica Bonuan.

Angelica Bonuan reports that there is currently 1 COVID-19 positive resident and 0 COVID-19 positive staff. During today's tele-visit, the following recommendations were made to the facility by Nurse Cristina Wong:

1. Contact Home Health Agencies on listing provided by CCL
2. Visitor COVID-19 Symptom Screening Log needs to have all symptoms listed and vaccination and exposure questionnaire.
3. Obtain more gowns and N95 masks for staff going into isolation room
4. Have staff professionally fit tested for N95 masks
5. Train staff how to clean face shields
6. Staff should be changing N95 masks each time they enter isolation room
7. Use dishwasher to wash dishes instead of handwashing dishes
8. Put hand washing signs in picture frame in bathrooms
9. Give infected resident bed baths while isolated instead of showers
10. Follow up with Local Public Health and contact them
11. Call Regional Center for PPE training
No deficiencies were cited as per California Code of Regulations, Title 22. This report was reviewed with Angelica Bonuan. A copy of the report will be sent to her for it to be signed and returned to CCL.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2021
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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