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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202656
Report Date: 02/09/2022
Date Signed: 02/11/2022 02:58:33 PM

Document Has Been Signed on 02/11/2022 02:58 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:MOUNT BLUE RESIDENTIAL CARE HOME INCFACILITY NUMBER:
435202656
ADMINISTRATOR:FREDRICKA SAFARFACILITY TYPE:
735
ADDRESS:1233 BRYAN AVETELEPHONE:
(415) 385-8900
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY: 6CENSUS: 6DATE:
02/09/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:FREDRICKA SAFARTIME COMPLETED:
09:30 AM
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Licensing Program Analyst (LPA) Steve Chang, and Licensing Program Manager (LPM) Romeo Manzano, conducted Technical Assistant through tele-inspection (Zoom), and met with Administrator (ADM) FREDRICKA SAFAR.

The purpose of this TA Tele visit was to review the facility COVID-19 infection mitigation plan and conducted inspection of the facility to ensure plan is being carried out and to provide support and guidance to staff in mitigating the spread of virus.

During tele-visit inspection, a tour of the facility was conducted which started at the main entrance to check COVID-19 signage and screening procedures. The facility has the COVID-19 posters at the main entrance including hand sanitizer, face masks, thermometer, glove, and a visitor log book at the screening station.

The facility common areas were inspected such as the kitchen, living room, family room, dinning area, and bathrooms were observed. There are 3 resident bedrooms, three bathrooms in facility. Trash cans were observed with covers. Paper towels with holders were observed. Some washing hands signs by the sinks were observed. Cloth towels were observed in the restrooms and kitchen. The resident bedrooms were observed. The beds in the bedrooms were observed 6 feet apart. ADM stated all the residents and staff are fully vaccinated and done with boosters. ADM request CCL office to provide PPEs. CCL office will prepare the PPEs for ADM to pick up.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2022
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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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: MOUNT BLUE RESIDENTIAL CARE HOME INC
FACILITY NUMBER: 435202656
VISIT DATE: 02/09/2022
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Based on today's inspection, the facility is being recommended the following:

1. Facility to post more COVID-19 signage on the main door.
2. Facility to put the COVID-19 questionnaires on the screening station.
3. Facility to put more hand sanitizers in common areas.
4. Facility to frequently wipe and disinfect high touch areas.
5. Facility to remove the cloth towels in kitchen and restrooms.
6. Facility to conduct staff training at least monthly or frequently such as donning and doffing PPE and COVID -19 updates.
7. Facility use of N95 mask by staff must have completed a N95 mask fitting test conducted by medical professional per CalOSHA.
8. Facility to have a laundry hamper inside the positive resident’s room, laundry hamper should have a double trash bag.
9. Do the laundry for negative residents first, then do the laundry for the positive residents.
10. Use high temperature hot water for laundry.
11. N95 Seal check reference:
https://www.cdc.gov/niosh/docs/2018-130/pdfs/2018-130.pdf
https://www.youtube.com/watch?v=oU4stQgCtV8
12. Facility to review PINs (Providers’ Information Notification) through CCLD website: www.ccld.ca.gov.
13. Facility to post the washing hands signs by the sinks.


No deficiencies cited during today's Tele Visit. Exit interview conducted with Administrator.
A copy of this report emailed to ADM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022
LIC809 (FAS) - (06/04)
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