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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202577
Report Date: 11/21/2020
Date Signed: 12/01/2020 03:42:32 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:SOMERSET SENIOR LIVINGFACILITY NUMBER:
435202577
ADMINISTRATOR:CONNORS, SONIAFACILITY TYPE:
740
ADDRESS:1050 ST ELIZABETH DRTELEPHONE:
(408) 217-9775
CITY:SAN JOSESTATE: CAZIP CODE:
95126
CAPACITY:40CENSUS: DATE:
11/21/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator/ Licensee Sonia ConnorsTIME COMPLETED:
02:20 PM
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LPA Steve Nguyen, LPM Brenda Chan, RM Vivien Hebling, PHD Jennifer Amaya, PHD Caitlin Steward, met with Administrator Sonia Connors today via virtual conference to conduct a Technical Assistance inspection.

Observations: Facility universal entrance had COVID signs and notices. Procedures for temperature checks, screening questionnaires for visitors, was present. Bathrooms had hand hygiene signs, soap dispensers and paper towels was observed. All direct care staff and kitchen staff was observed to wear N-95 masks and face shields (kitchen staff had gloves on during food preparations). EPA registered disinfectants was present and properly stored/ locked in cabinet at facility. PPE stations was observed outside of residents room, ready for staff to use, along with proper signage (LPA advised Administrator to put up signs indicating, Full PPE must be Worn, prior to entering Covid Positive resident's room).

Based on the observations, the following recommendations were made by the PHD:

1. Adequate staffing must be maintained
2. Cohort positive residents as much as possible
3. N-95 mask fitting is a priority
4. Redirect residents to observe Covid protocols

END OF REPORT
SUPERVISOR'S NAME: George NwaforTELEPHONE: (408) 324-2116
LICENSING EVALUATOR NAME: Steve NguyenTELEPHONE: (650) 676-0051
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2020
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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