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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202548
Report Date: 11/13/2020
Date Signed: 11/17/2020 02:38:05 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:MINA'S ELDERLY CARE HOME 2FACILITY NUMBER:
435202548
ADMINISTRATOR:ABBASVAND, MINAFACILITY TYPE:
740
ADDRESS:3668 SYDNEY COURTTELEPHONE:
(408) 649-3628
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY:6CENSUS: 5DATE:
11/13/2020
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Mina AbbasvandTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Grace Davis and LPM Romeo Manzano conducted a Covid-19 Technical Assistance tele-visit via Face-time. Due to COVID-19 preventive measures, facility visits have been suspended. LPA met with Administrator(ADM) Mina Abbasvand and also present is Health Facility Evaluator Nurse (HFEN) Angela Pruitt.

The facility current census is five (5). 1 out of the 5 residents is under hospice care. There are a total of 3 staff at the facility. All five (5) residents have their bedrooms and 1 staff bedroom. Residents and staff are self-quarantening in the facility. ADM is in contact with Local Public Health.

During today's inspection, the facility was virtually toured inside and out. The facility has signage of COVID-19 in the main door and common areas. Facility is not admitting visitors except essential workers (medical professionals). Screening station was observed by the main entrance with hand sanitizer, gloves and gowns. ADM stated that medical professionals put on PPEs prior to entry the facility and/or residents' rooms. Soiled PPE's are removed inside the residents' room in the garbage bin with cover. The facility has common bathroom with signage with hand soap (pump), paper towel and garbage bin. PPE's supplies including cleaning and disinfectant supplies were observed and adequate.

ADM stated dining is off limit and residents' meals are being served inside their bedrooms. Facility food supplies are being delivered weekly by ADM's husband. Residents' medications are refilled for at least 30 days to 3 months.

ADM operates 4 RCFE facilities. 2 out of the 4, ADM is the designated Administrator while the other two are assigned to her husband. ADM monitor facilities through daily phone calls and her husband is assisting and one on-call Administrator.

No deficiencies observed during this visit. Exit Interview conducted with ADM. A copy of this report is e-mailed to the facility for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Grace DavisTELEPHONE: (408) 314-5102
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020
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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