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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202621
Report Date: 01/21/2022
Date Signed: 01/21/2022 02:51:23 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:IVY PARK AT SAN JOSEFACILITY NUMBER:
435202621
ADMINISTRATOR:MICHAEL FOUNTAINFACILITY TYPE:
740
ADDRESS:4855 SAN FELIPE RDTELEPHONE:
(408) 223-1312
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY:140CENSUS: 98DATE:
01/21/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Sara PostTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) David Marrufo Nurse Mirabelle Villamin conducted a tele-visit via Zoom to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility and met with Sara Post.

The Administrator reports that there are currently 2 COVID-19 positive residents and 3 COVID-19 positive staff.

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

1. Post visitor signs at facility entrance explaining mask and visitor requirements.
2. Place sanitizing wipes at front desk to sanitize the thermometer.
3. Add signs in hallway seating areas to promote social distancing.
4. Communal dinning areas should only have two chairs per table.
5. Donning/Doffing sign needs to be near all quarantine carts.
6. Have staff remove N95 after use in quarantine room and dispose of in the trash can with lid outside of the room.
7. Post sign stating maximum amount of people allowed on the elevator at once.
8. Bathroom near staff break room needs to be sanitized after each use.
9. PPE and masks should be used by staff as they enter Memory Care unit.

No deficiencies were cited as per California Code of Regulations, Title 22.

This report was reviewed with with Sara Post. A copy of the report will be sent to her for it to be signed and returned to CCL.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022
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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