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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202670
Report Date: 02/28/2022
Date Signed: 03/01/2022 08:03:59 AM


Document Has Been Signed on 03/01/2022 08:03 AM - 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:SILICON VALLEY SENIOR CARE HOMEFACILITY NUMBER:
435202670
ADMINISTRATOR:LADWIG, JUVELYN IRISHFACILITY TYPE:
740
ADDRESS:5255 RAFTON DRTELEPHONE:
(408) 677-4405
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:6CENSUS: 4DATE:
02/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:IRISH LADWIGTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Steve Chang, and Program Clinical Consultant (PCC) Kathleen Weiss conducted Technical Assistant - PCC through tele-inspection (Zoom), and met with Administrator (ADM) Irish Ladwig.

The purpose of this TA PCC 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 screening questionnaire forms, hand sanitizer, face masks, thermometer, glove, and a visitor log book at the screening station.
Two staff were observed in facility.

The facility common areas were inspected such as the kitchen, living room, dinning area, bathrooms were observed. There are 4 resident single bedrooms, 1 resident shared room, 1 staff live-in bedroom, 2 resident bathrooms, and 1 staff restroom in facility. One isolation room was observed. Trash cans with covers, paper towels with dispenser or holders, and washing hands signs by the sinks were observed. ADM stated only two residents are allowed at dining are at one time. The laundry room was observed and inspected. The resident bedrooms were inspected. PPE supplies were observed sufficient.

ADM stated all the residents and staff are fully vaccinated and finished with booster shots.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2022
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: SILICON VALLEY SENIOR CARE HOME
FACILITY NUMBER: 435202670
VISIT DATE: 02/28/2022
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Based on today's inspection, the facility is being recommended the following:

1. Facility to frequently wipe and disinfect high touch areas.
2. Facility to conduct staff training at least monthly or frequently such as donning and doffing PPE and COVID -19 updates.
3. Facility use of N95 mask by staff must have completed a N95 mask fitting test conducted by medical professional per CalOSHA.
4. Do the laundry for negative residents first, then do the laundry for the positive residents.
5. N95 Seal check reference:
https://www.cdc.gov/niosh/docs/2018-130/pdfs/2018-130.pdf
https://www.youtube.com/watch?v=oU4stQgCtV8
6. Facility to review PINs (Providers’ Information Notification) through CCLD website: www.ccld.ca.gov.
7. Facility to reference https://youtu.be/H4jQUBAlBrI - donning PPE.
8. facility to reference https://youtu.be/PQxOc13DxvQ - doffing PPE.
9. facility to reference https://youtu.be/KmyxsnuREGs - How does viruses spread from surfaces to people.
10. facility to reference https://youtu.be/pIAH2l9Eg6g - How does viruses make you sick.
11. Facility to reference https://youtu.be/TCa7Gg1NUD4 - Why does contact time matter for disinfection.

No deficiencies cited during today's Tele Visit. Exit interview conducted with ADM.
A copy of this report emailed to ADM for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2022
LIC809 (FAS) - (06/04)
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