<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202665
Report Date: 12/31/2021
Date Signed: 12/31/2021 10:28:55 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:LOMA CLARA SENIOR LIVINGFACILITY NUMBER:
435202665
ADMINISTRATOR:JENNIFER BRUHNFACILITY TYPE:
740
ADDRESS:16515 BUTTERFIELD BLVDTELEPHONE:
(669) 258-3500
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY:89CENSUS: 59DATE:
12/31/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Jennifer BruhnTIME COMPLETED:
10:10 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 Analyst (LPA) Christine Dolores conducted a scheduled technical assistance visit and met with Executive Director, Jennifer Bruhn. During visit, LPA conducted a Facetime tour of the facility with PCC Toni Rivera and LPM Jackie Jin. The purpose of the visit was to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility.

LPA, PCC, and LPM toured the facility to include the central entry point, screening area, assisted living (AL) dining room, AL private dining room, living room, bathrooms, and memory care (MC) to include the dining room, activity room, and common bathroom. All staff are N95 fit tested.

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

1. Maintain a supply of disposable masks, gloves, and hand sanitizer accessible at the front desk for all visitors, staff, and residents
2. Place a 20 second hand-washing sign in all bathrooms
3. Maintain social distancing in all common areas to include the dining rooms
4. When 1 MedTech in MC is passing out medications , ensure staff first start with the negative residents and then move onto positive residents
5. Remove all common cloth rags and cloth towels. Use paper towels or disinfectant wipes to clean all surfaces
6. Maintain hand sanitizer in all PPE carts used for isolation rooms
No deficiencies were cited as per California Code of Regulations, Title 22. This report was reviewed via telephone with Jennifer Bruhn 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: 12/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1