<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202751
Report Date: 03/04/2021
Date Signed: 03/30/2021 12:20:57 PM

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:EPIONE RESIDENTIAL CAREFACILITY NUMBER:
435202751
ADMINISTRATOR:JACOBS, LILIBETH P.FACILITY TYPE:
740
ADDRESS:1212 S MARY AVETELEPHONE:
(408) 746-5605
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY:6CENSUS: 6DATE:
03/04/2021
TYPE OF VISIT:Case Management - COVID-19ANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Lilibeth JacobsTIME COMPLETED:
01:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Due to COVID-19 pandemic, Licensing Program Analyst (LPA) Yatfai Eric Ng partnered with Health Facilities Evaluator Nurse (HFEN) Sheryll D. Falcone from the California Department of Public Health, conducted a tele-Case Management - COVID-19 via FaceTime, to provide a technical assistance to prevent and mitigate the spread of COVID-19 at the facility. LPA and HFEN met with the Licensee (LIC) Lilibeth Jacobs.

The virtual tour started at the entrance of the facility that had the signs to remind everyone to practice social distancing and wear masks. At the entrance, there was a screening station with thermometer and questionnaire to screen staff and visitors before they could enter. LPA observed staff in the facility wore masks at all time. Restrooms were toured that had soap, paper towels, trash bins with lids readily available. Residents' clothes were washed with hot water without commingling. Dishes are washed with dish soap and hot water. There was no positive COVID-19 case in the facility currently. However, LPA and HFEN discussed with LIC what procedures to follow in isolating COVID-19 resident in his or her own room.

Following infection control practices were suggested:
  1. Post Provider Information Notice PIN 20-38-ASC to explain visitation limitation to visitors
  2. Enforce the policy of having only one entry and one exit point using the front entrance
  3. Post more signs in the common areas and in the break area to promote social distancing
  4. Remove cloth towels in kitchen and shared restrooms
  5. Male staff should shave daily before putting on any mask
  6. Review PIN 21-10-ASC about N95 mask fit testing to fulfill Cal/OSHA respiratory protection requirements

No deficiency cited during visit.

This report was emailed to the LIC to review and to obtain signature. Additional resource about COVID-19 was also sent to LIC for reference.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1