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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202724
Report Date: 01/28/2021
Date Signed: 02/03/2021 08:34:05 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:GOLDWOOD SENIOR CARE HOMEFACILITY NUMBER:
435202724
ADMINISTRATOR:JEANETTE MONGEONFACILITY TYPE:
740
ADDRESS:2692 GOLDWOOD CTTELEPHONE:
(669) 234-3544
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY:6CENSUS: 6DATE:
01/28/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Irish Ladwig/Jeanette MongeonTIME COMPLETED:
01:54 PM
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Licensing Program Analyst (LPA) Gladys Kuizon conducted a Technical Assistance tele-visit today and met with Administrators Irish Ladwig and Jeanette Mongeon.

Present during the tele-visit were Community Care Licensing (CCL) Program Clinical Consultant (PCC) Paul Portem and Licensing Program Manager (LPM) Romeo Manzano.

A tour of the facility was conducted. The facility's screening procedures were reviewed. COVID-19 postings were observed throughout the facility including on the main entrance, hallways, and isolation room. Personal Protective Equipment (PPE) donning and doffing guides were posted where staff was expected to don and doff PPE. Covered trash bins were available. Seating furniture in the dining and living rooms were marked to promote social distancing. The facility currently has 3 residents in the facility. 1 resident (R1) was observed in the family room. R1 stated staff takes care of R1 and R1 is feeling well. There is adequate staffing and PPE supplies in the premises.

The following were discussed today:

1. Provider Information Notice (PIN) 20-38-ASC was discussed to guide Administrators of isolation procedures when accepting back residents who are returning from an acute care facility or higher level of care facility. Administrators were advised to keep up to date with CCL PINs and Public Health orders.

2. Facility staff may use surgical or KN95 masks instead of N-95 masks if there are no active positive COVID-19 cases in the facility. Full PPE gear (face shield, N-95 mask, gloves, and isolation gown) shall be worn when caring for a COVID-19 positive resident who is under isolation.

This report was provided to Administrators via email for signature.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2021
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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