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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202754
Report Date: 01/22/2021
Date Signed: 02/09/2021 09:14:16 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:VILLA SERENA OF MORGAN HILLFACILITY NUMBER:
435202754
ADMINISTRATOR:ELSOUSOU, NICOLASFACILITY TYPE:
740
ADDRESS:16095 CHURCH STREETTELEPHONE:
(408) 778-5683
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY:20CENSUS: 11DATE:
01/22/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Georgina RuizTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Karen Taku and Licensing Program Manager’s (LPMs)) Vivian Helbling and Romeo Manzano conducted a tele-visit regarding COVID-19 prevention measures. LPA and LPM’s met with Patient Care Coordinator (PCC) Georgina Ruiz.

PCC is receiving guidance from SCCPH representative Lily Xia. SCCPH is scheduled to conduct a second mass testing on 1/23/2021. Per PCC, the facility has a total of 11 residents. Six are on hospice, 10 are covid+, and one resident was hospitalized due to covid symptoms. All resident is in isolation and proper PPE signage has been posted outside each resident’s room. Home Health Aides (Bridge Seasons and Vita) visit Monday-Friday, to assist with bathing, feeding, and toileting. Health aides sign in and out, and are screened for covid symptoms prior to entry. All emergency contacts were notified of the covid outbreak and only window visits are allowed.

Per PCC, she does not foresee a staffing issue. The facility has a total of 11 employees and four are covid+. Three employees are scheduled on the morning and evening shift, and one during the night shift. Employee are screen for covid symptoms prior and during their shift. PPE is also worn by all staff throughout their shift. PPE is changed and discarded appropriately when caring for negative and positive covid residents. Facility has foot operated trash cans and appropriate PPE. Facility staff is only performing bed baths to prevent the spread of covid. Negative facility staff is responsible for preparing and delivering all meals to each resident’s door.

Per PCC, all staff received PPE training in October 2020. The facility is disinfected every two hours with odoban. “OdoBan® cleans, disinfects, and sanitizes surfaces.” Residents are monitored/vital signs are taken every two hours, including respiration rate.

Per PPC, she will share all correspondence and guidance from SCCPHD with LPA and LPMS.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Karen TakuTELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2021
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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