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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202616
Report Date: 02/14/2022
Date Signed: 02/14/2022 04:11:08 PM


Document Has Been Signed on 02/14/2022 04:11 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:KEENE KAREFACILITY NUMBER:
435202616
ADMINISTRATOR:GAMBOA, ABIGAILFACILITY TYPE:
740
ADDRESS:2488 GLEN ELM WAYTELEPHONE:
(408) 531-9678
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY:6CENSUS: 5DATE:
02/14/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:GAMBOA, ABIGAILTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Christine Dolores conducted a scheduled technical assistance visit and met with Administrator, Abigail Gamboa. During visit, LPA conducted a Zoom tour of the facility with Program Clinical Coordinator (PCC), Kathleen Weis and Licensing Program Manager, Sarah Yip. The purpose of the visit was to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility.

During today's tele-visit, the following recommendations were made to the facility by PCC:

1. Contact Local Public Health regarding test results from COVID positive resident
2. Continue isolating resident until given further guidance from Local Public Health
3. Post a "mask required" sign at the front door for all visitors and staff
4. Create a COVID-19 symptom screening log at the entry point for all visitors and staff
5. Post an "isolation" sign outside the door of the isolation room for easy detection
6. Replace all trash cans with a foot-operated trash can with lid throughout the facility to include the bathrooms, resident rooms, and kitchen
7. Place a foot operated trash can with lid inside of the isolation room
8. Place "how to hand wash" sign in the other bathroom
9. Remove all cloth towels throughout facility to prevent cross contamination
10. Designate a bathroom for COVID positive only and COVID negative residents and staff
11. Call staffing agencies listed in the facility mitigation plan to confirm available staff when staffing shortage arise
12. Provide N95 fit testing to all facility staff
No deficiencies were cited as per California Code of Regulations, Title 22. This report was reviewed via telephone with Administrator, Abigail Gamboa and a copy of the report was emailed for signature.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2022
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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