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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202577
Report Date: 12/02/2020
Date Signed: 01/04/2021 11:23:28 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: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: 32DATE:
12/02/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Sonia ConnorsTIME COMPLETED:
03:57 PM
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Due to COVID-19 pandemic, Licensing Program Analysts (LPAs) Yatfai Eric Ng and Jackie Jin, partnered with a Health Facilities Evaluator Nurse (HFEN) Rebekah Bird-Wohlgemuth from the California Department of Public Health, conducted a Case Management - Other - tele-visit via FaceTime, to provide a technical assistance to prevent and mitigate the spread of COVID-19 at the facility. LPAs and HFEN met with the Licensee Sonia Connors.

LPAs and HFEN toured the facility virtually with the Licensee holding the camera to show around the facility. LPAs and HFEN observed the Licensee wore face shield and N-95 mask at the start of the tour.

LPAs and HFEN randomly toured room 202, 203 on the second floor, and room I-35 and I-38 on the first floor, which were the isolation rooms. The Licensee put on gown before entering the isolation and took down the gown without LPAs asking. LPAs and HFEN observed there were covered trash bins. The Licensee showed that those covered trash bins only contained used personal protective equipment (PPE). The uncovered trash bins did not contain any PPE. The Licensee stated she instructed staff and told residents that the covered trash bins were for the used PPE and solid waste; uncovered trash bins were for the items such as paper and non-PPE. Trash bins were emptied at the end of each shift. LPAs and HFEN also observed worn clothes were stored inside a covered bin. The Licensee stated staff only washed the soiled clothes separately for each resident. The bin would be sanitized before carrying the clean clothes back to the residents.

LPAs observed a staff who was assisting a resident getting back to the resident's room was wearing PPE.

No deficiency cited during visit.

This report was emailed to the Licensee to review and to sign.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2020
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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