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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202541
Report Date: 06/10/2022
Date Signed: 06/10/2022 04:44:15 PM

Document Has Been Signed on 06/10/2022 04:44 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:NORTH VALLEY HOMEFACILITY NUMBER:
435202541
ADMINISTRATOR:GOLTIAO, JANETTEFACILITY TYPE:
735
ADDRESS:3578 DINNY STREETTELEPHONE:
(408) 802-3119
CITY:SANTA CLARASTATE: CAZIP CODE:
95054
CAPACITY: 6CENSUS: 6DATE:
06/10/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:JANETTE GOLTIAOTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Steve Chang, Licensing Program Manager (LPM) Romeo Manzano and Program Clinical Consultant (PCC) Helen Shi conducted Technical Assistant - PCC through tele-inspection (Zoom), and met with Administrator (ADM) JANETTE GOLTIAO.

The purpose of this TA PCC 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.

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 signage at the main entrance door, and screening station with the following: screening questionnaire, hand sanitizer, thermometer, face masks, and a visitor log.

The facility common areas were inspected such as the kitchen, living room, dinning area, and bathrooms. There are 5 resident bedrooms and 4 bathrooms at facility. Trash cans were observed with covers. Some paper towels were observed without holders. Washing hand posters were observed by the sink in restrooms and kitchen. Laundry room was observed and inspected. Gown was observed to reuse. PPE supplies were observed sufficient. ADM stated all the staff and residents are fully vaccinated and boosted

Based on today's inspection, below are the recommendations:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2022
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: NORTH VALLEY HOME
FACILITY NUMBER: 435202541
VISIT DATE: 06/10/2022
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1. Facility not to reuse gown, face mask, gloves. .
2. Facility to make sure that paper towels must be in paper towel holders.
3. Facility to make sure Laundry hampers be lined with trash bags (black) and hampers with lid.
4. Facility to To wash the COVID negative first and last the COVID positive for laundry.
5. Facility to frequent wipe down common/ high touch areas with EPA grade disinfectants.
6. Attend training (online/class) on Infection prevention control (IPC), PPEs conducted by CDC or the county public health.
7. Facility to have N95 fitting test for staff who are caring for positive residents.

Refer provider to the following PINs and CDPH recommendations:

1. PIN 22-16-ASC UPDATED DIAGNOSTIC AND RESPONSE TESTING GUIDANCE FOR CORONA VIRUS DISEASE 2019 (COVID-19).

2. PIN 22-14-ASC INFORMATIONAL CALL REGARDING CORONA VIRUS DISEASE 2019 (COVID-19) AND INFECTION CONTROL PLAN GUIDANCE.

3. PIN 22-13-ASC ADULT AND SENIOR CARE (ASC)- UPDATED REGULATIONS FOR INFECTION CONTROL REQUIREMENTS.

4. PIN 22-09-ASC UPDATED GUIDANCE ON QUARANTINE AND ISOLATION FOR FACILITY STAFF EXPOSED TO COVID-19 AND RETURN TO WORK FOR FACILITY STAFF WHO TEST POSITIVE FOR CORONA VIRUS DISEASE 2019 (COVID-19).
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022
LIC809 (FAS) - (06/04)
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