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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202724
Report Date: 01/21/2021
Date Signed: 01/25/2021 03:34:32 PM


Document Has Been Signed on 01/25/2021 03:34 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: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: 5DATE:
01/21/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:09 PM
MET WITH:Jeanette MongeonTIME COMPLETED:
04:44 PM
NARRATIVE
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Licensing Program Analyst (LPA) Gladys Kuizon conducted a Case Management tele-visit today and met with Administrator Jeanette Mongeon. Due to COVID-19 restrictions, facility site visits have been suspended.

On January 18, 2021, the Department received a written incident report from the facility notifying the Department that there are 7 confirmed positive COVID-19 cases in the facility. The written report stated that the first positive COVID-19 case was confirmed on January 12, 2021.

Santa Clara County Public Health conducted mass testing on January 14, 2021 and informed the facility of positive results on January 15, 2021.

At 4:09 PM, LPA toured the facility and observed 3 residents and 2 staff present in the facility. Staff were observed wearing N-95 masks. LPA advised Administrator to ensure that COVID-19 negative staff wear full Personal Protective Equipment (PPE) including N-95 mask, gloves, face shield, and isolation gown. Administrator confirmed understanding. COVID-19 related posters are displayed throughout the facility including the main entrance. Residents confirmed they are feeling well and not exhibiting COVID-19 symptoms at this time.

A deficiency was cited today. Please see LIC 809-D. This report was discussed with Administrator Jeanette Mongeon and a copy provided via email for signature.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:
DATE: 01/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2021
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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Document Has Been Signed on 01/25/2021 03:34 PM - It Cannot Be Edited

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: GOLDWOOD SENIOR CARE HOME
FACILITY NUMBER: 435202724

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
01/22/2021
Section Cited

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87211 REPORTING REQUIREMENTS. (a)(2)
Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents ...shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.
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This requirement was not met as evidenced by: Facility reported a COVID-19 outbreak to CCLD more than 24 hours after receiving confirmed positive test results. This posed an immediate risk to the health & safety of residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:
DATE: 01/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2021
LIC809 (FAS) - (06/04)
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