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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202664
Report Date: 05/13/2021
Date Signed: 05/13/2021 04:37:49 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:MINA'S ELDERLY CARE HOME 3 LLCFACILITY NUMBER:
435202664
ADMINISTRATOR:ABBASVAND, MINAFACILITY TYPE:
740
ADDRESS:427 RICHLEE DRTELEPHONE:
(408) 272-7946
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:6CENSUS: 6DATE:
05/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Mina AbbasvandTIME COMPLETED:
02:36 PM
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Licensing Progrm Analysts Ryker Heberle, Anna Bui, and Eric Ng (LPAs) conducted an unannounced infection control site visit on 05/13/2021 at 1:05pm. LPAs met with facility administrator Mina Abbasvand (Admin).

LPAs toured the facility, front hall way including 3 bathrooms, kitchen, dining room, living room, medicine/PPE cabinet, and porch visitation area.

All staff members observed to be wearing masks. Visiting family member observed to be wearing mask. No residents in facility observed to be wearing masks. LPAs advised Admin to encourage residents to wear masks when in close quarters in common area.

Facility observed to have designated entry point for universal symptom screening with questionnaire. Facility screening questionnaire observed to be incomplete. All restrooms observed to be adequately stocked with paper towels, hand sanitizer, and hand soap. Bathrooms observed to not have foot pedal operated trash cans. LPAs reminded Admin to replace trash hand operated trash cans with foot pedal operated trash cans., Admin stated that they would replace the trash cans.

Facility observed to have adequate supply of PPE

Advisory notes issued, see LIC 9102.

This report reviewed with Administrator Mina Abbasvand and a copy igned report provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021
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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