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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202754
Report Date: 08/17/2021
Date Signed: 08/19/2021 08:20:04 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: DATE:
08/17/2021
TYPE OF VISIT:Case Management - COVID-19ANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Claudia EliasTIME COMPLETED:
05:20 PM
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Licensing Program Analyst (LPA) Christine Dolores conducted a scheduled technical assistance visit and met with Lead Staff, Claudia Elias. During visit, LPA conducted a Facetime tour of the facility with Program Clinical Coordinator (PCC) Helen Shi 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. Lead Staff, Claudia Elias reports that there are currently 6 COVID-19 positive residents and 1 COVID-19 positive staff.

LPA toured the facility inside and out to include: entry point, common sitting area, dining room, resident rooms, green zone, red zone, bathrooms, and outdoor seating. LPA observed hand-washing signs in the bathrooms, visitor/staff screening logs, donning and doffing posters outside each residents room, and sufficient PPE supplies.

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

1. Always keep COVID-positive resident rooms closed, at all times
2. Place plastic shield/covering separating red and green zone
3. Place trash can with lid next to exit door in the red zone
4. Designate a back door for staff entrance and exit in red zone
5. Place a trash can with lid on the outside of COVID-positive room for disposal of N95 masks in green zone
6. Post COVID-19 postings throughout facility
7. Monitor residents who are asymptomatic every 4 hours
8. Monitor residents are who symptomatic more often, as needed

See LIC-809C for more information.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021
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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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: VILLA SERENA OF MORGAN HILL
FACILITY NUMBER: 435202754
VISIT DATE: 08/17/2021
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During visit, Lead Staff Claudia Elias closed all COVID-positive resident doors. Manager also placed trash can with lid outside the door of COVID-positive resident in green zone area.
No deficiencies were cited as per California Code of Regulations, Title 22. This report was reviewed via tele-visit and email copy was provided to Lead Staff, Claudia Elias, for signature.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021
LIC809 (FAS) - (06/04)
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