435202621-9-8-2021-26-AS-CDOS-C6NLEK-20210908084139

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202621
Report Date: 09/03/2021
Date Signed: 09/08/2021 08:41:44 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:	SUNRISE VILLA SAN JOSE		FACILITY NUMBER:	435202621
ADMINISTRATOR:	ZEPEDA, JESSICA		FACILITY TYPE:	740
ADDRESS:	4855 SAN FELIPE RD		TELEPHONE:	(408) 223-1312
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95135
CAPACITY:	140	CENSUS: 81	DATE:	09/03/2021
TYPE OF VISIT:	Case Management - COVID-19	ANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Michael Fountain		TIME COMPLETED:	10:30 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPA) Christine Dolores conducted a scheduled technical assistance visit and met with Executive Director (ED), Michael Fountain. During visit, LPA conducted a FaceTime tour of the facility with PCC, Lori Kopplinger and LPM, Sarah Yip. The purpose of the visit was to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility. ED reports 7 COVID-19 positive residents and 2 COVID-19 positive staff. 2 COVID-19 positive residents will be cleared today. LPA, LPM, and PCC toured the facility inside and out to include the entry point, screening station, common areas, dining room, activity room, common bathroom, staff break room, PPE station, and courtyard. During today's tele-visit, the following recommendations were made to the facility by PCC Lori Kopplinger: 1. Add complete COVID-19 symptoms to the visitor/staff screening log 2. Remove chairs in the activity room to ensure social distancing 3. Remove chairs in the dining room to limit 2 per table, to ensure social distancing 4. Remove all tablecloths in the dining room area for best practices in reducing the spread of the virus 5. Maintain a clean and dirty section for PPE supplies outside each COVID-19 positive room. Place trash bin with lid closer to the room, and place PPE cart away from the trash bin to reduce cross-contamination 6. Replace donning / doffing poster outside of each COVID-19 positive room 7. Post maximum capacity sign outside of the break room 8. Designate a separate break room for staff caring for COVID-19 positive residents, to be located in the courtyard or in the private dining room area See LIC809-C for more information.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SUNRISE VILLA SAN JOSE	FACILITY NUMBER: 435202621
	VISIT DATE: 09/03/2021

NARRATIVE

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9. Ensure staff caring for COVID-19 positive residents are disposing face shields with foam, after each use
10. Place a foot operated trash bin with lid in the common restrooms
11. Post COVID-19 postings throughout facility, to include front entrance and common areas

During visit, staff had placed foot operated trash bin with lid closer to the COVID-19 positive resident's room. Staff had moved the PPE cart along with boxes of gloves away from the trash bin.

PCC emailed LPA COVID-19 information on the list of symptoms and provided a new donning/doffing poster. LPA will email ED COVID-19 information, to include additional COVID-19 posters.
No deficiencies were cited as per California Code of Regulations, Title 22. This report was reviewed via tele-visit and email copy was provided to Executive Director, Michael Fountain, for signature.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021

LIC809 (FAS) - (06/04)

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