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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202665
Report Date: 02/23/2022
Date Signed: 02/23/2022 02:34:35 PM


Document Has Been Signed on 02/23/2022 02:34 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: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: 69DATE:
02/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Diana SmithTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Christine Dolores conducted an unannounced annual required inspection to focus on infection control. LPA met with Administrator, Diana Smith.

During today's visit LPA toured the facility inside and outside. LPA observed the front entrance of the facility to include posters of required mask, feeling ill, symptoms of COVID-19, and CDC guidance for visitors proof of vaccination or proof of a negative COVID test. Facility has a central entry point and symptom screening area for all visitors and staff. Hand sanitizer is made available. All fire exit routes were free and clear of obstructions.

Elevators observed to have signs for social distancing and required mask. Bathrooms observed to be supplied with hygiene products and paper supplies. Hand washing signs were posted in bathrooms and throughout facility. Foot operated trash can with lid observed in the bathrooms and throughout the facility. Assisted living dining room tables and chairs were spread apart to ensure social distancing. Social distancing signs was observed on each table.

LPA observed facility to have enough PPE supplies. Facility disinfect and sanitize high touch surfaces daily and as needed. Facility has a mitigation plan in place to prevent the spread of COVID-19. All staff are N95 fit tested.

No deficiencies cited during today's visit per California Code of Regulations, Title 22.

This report was reviewed with Administrator, Diana Smith and a copy of this report was provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2022
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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