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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202733
Report Date: 02/04/2022
Date Signed: 02/04/2022 04:28:18 PM

Document Has Been Signed on 02/04/2022 04:28 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:LIFE SERVICES ALTERNATIVES CALLE VIENTO HOMEFACILITY NUMBER:
435202733
ADMINISTRATOR:VICENTE, ROGELIOFACILITY TYPE:
735
ADDRESS:545 CALLE VIENTOTELEPHONE:
(408) 727-3493
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 4CENSUS: 3DATE:
02/04/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Rogelio VicenteTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Christine Dolores conducted a scheduled technical assistance visit and met with Administrator Rogelio Vicente. During visit, LPA conducted a Zoom tour of the facility with Program Clinical Coordinator (PCC) Toni Rivera and Licensing Program Manager (LPM) Jackie Jin. The purpose of the visit was to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility.

During today's tele-visit, the following recommendations were made to the facility by PCC:

1. Add a complete list of COVID-19 symptoms to screening log for visitors and staff
2. Provide N95 fit testing for facility staff
3. Remove all cloth towels in common areas
4. Add "isolation" sign on the doors of the COVID positive resident to quickly identify the room is in isolation
5. Line COVID positive residents laundry bin with a plastic bag to prevent cross contamination when transferring laundry to the laundry room
6. Ensure staff are wearing full PPE when handling COVID positive residents laundry
7. Maximize staff time when caring for COVID positive residents to minimize the contact throughout the day

No deficiencies were cited as per California Code of Regulations, Title 22. This report was reviewed via telephone with Administrator Rogelio Vicente and a copy of the report was emailed for signature.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2022
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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