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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202744
Report Date: 03/11/2021
Date Signed: 04/01/2021 09:59:13 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:WESTMONT OF MILPITASFACILITY NUMBER:
435202744
ADMINISTRATOR:BRAVO, SHERYLFACILITY TYPE:
740
ADDRESS:80 CEDAR WAYTELEPHONE:
(408) 770-9575
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY:225CENSUS: 6DATE:
03/11/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Emina OkanovicTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted a Technical Assist (TA) Visit via FaceTime with Emina Okanovic LVN and Marylene Majeska CDPH Health Facilities Evaluator Nurse (HFEN). The purpose of the visit was to provide technical assistance for Infection Prevention and Control guidelines for Adult and Senior Care facilities. LPA conducted a virtual tour of the facility.

The following recommendations were discussed:

1. Post Mask signage at entrance of the facility.
2. Post Hand Washing signage near the activity room sink and other common area bathroom sinks.
3. Utilize foot operated trash cans in the break room, common area bathrooms and isolation room(s).

Report reviewed with Emina Okanvoivic and copy emailed for signature.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE:
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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