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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202665
Report Date: 02/10/2023
Date Signed: 02/10/2023 12:31:45 PM


Document Has Been Signed on 02/10/2023 12:31 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:LOMA CLARA SENIOR LIVINGFACILITY NUMBER:
435202665
ADMINISTRATOR:JAIRUS CABUENAFACILITY TYPE:
740
ADDRESS:16515 BUTTERFIELD BLVDTELEPHONE:
(669) 258-3500
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY:89CENSUS: 66DATE:
02/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Jairus CabuenaTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility’s annual inspection focusing on infection control. LPA met with Executive Director, Jairus "Jett" Cabuena.

During visit, LPA toured the facility with ED to include generations (memory care), 3 resident units in generations, assisted living, common dining rooms, activity rooms, bathrooms, and kitchen. All staff observed wearing a face covering.

Facility temperature maintained between 68 - 84 degrees Fahrenheit. All fire exits were free and clear of obstruction.

Facility has a designated entry point for symptom screening, temperature check, and sign-in. Hand sanitizer and face masks were available at entry. COVID-19 posters posted at the entry to include a required mask sign, symptoms of COVID, and visitation guidelines. Bathrooms supplies with hand washing sign, hygiene products, and paper supplies. Facility staff clean and disinfect multiple times daily and as needed. LPA observed the facility’s Personal Protective Equipment (PPE) supplies. Facility has procedures to isolation and testing for COVID-19. Staff are N95 fit tested.

The following posters observed throughout the facility to include cough/sneeze etiquette, hand washing, proper ways to wear a face mask, and symptoms of COVID-19.

No deficiencies were cited per California Code of Regulations, Title 22. Advisory note provided. See LIC9102. This report was reviewed with Executive Director, Jairus "Jett" Cabuena and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2023
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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