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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202568
Report Date: 01/28/2021
Date Signed: 02/01/2021 08:18:31 AM

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:COMPASSIONATE ELDERCARE UNDAJON RCFEFACILITY NUMBER:
435202568
ADMINISTRATOR:MONGEON,JEANETTEFACILITY TYPE:
740
ADDRESS:683 UNDAJON DRIVETELEPHONE:
(408) 914-1147
CITY:SAN JOSESTATE: CAZIP CODE:
95133
CAPACITY:6CENSUS: 6DATE:
01/28/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Irish LadwigTIME COMPLETED:
10:41 AM
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Licensing Program Analyst (LPA) Grace Davis conducted a Covid-19 Technical Assistance tele-visit via Zoom. The purpose of this tele-visit is to provide assistance regarding covid-19 control and mitigation plan. Due to COVID-19 preventive measures, facility visits have been suspended. LPA met with Licensee Irish Ladwig also present is HFEN nurse Sheryll Falcone.

5 Of 6 residents and 1 staff have been tested positive with COVID-19 as a result of a mass testing on 01/17/2021.

Santa Clara Public Health is aware of COVID-19 cases in the facility.

During today's virtual inspection, the facility has signage of COVID-19 in the main door and common areas. The screening station have thermometer, hand sanitize, disinfectant wipes and log in sheet. The facility has common bathroom with signage, hand soap, paper towels and garbage bin.

HFEN nurse recommend that covid-19 positive residents should assess and monitor at least every 4 hours.

No deficiencies observed during this visit. Exit Interview conducted with licensee. 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: 01/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2021
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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