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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202759
Report Date: 11/23/2020
Date Signed: 11/24/2020 12:26:14 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:WESTGATE VILLAFACILITY NUMBER:
435202759
ADMINISTRATOR:TAYAG, AIDAHFACILITY TYPE:
740
ADDRESS:5425 MAYME AVENUETELEPHONE:
(408) 366-6510
CITY:SAN JOSESTATE: CAZIP CODE:
95129
CAPACITY:60CENSUS: 43DATE:
11/23/2020
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Aidah TayagTIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Steve Chang, Licensing Program Manager Romeo Manzano, and Program Clinical Consultant Clarita D. Dela Cruz conducted a tele visit with PCC via facetime. Due to COVID-19 preventive measures, facility visits have been suspended. LPA met with Administrator (ADM) Aidah Tayag. The facility current census is 43. ED stated today the facility has the second mass test.

During the today's inspection, the facility was virtually toured inside and out. The facility has posters of COVID-19 at the main entrance, common area, hallways, and restrooms. The facility has the hand sanitizers at the common area and restrooms with trash bins with lid (foot pedal). Per ADM, all staff and residents have their flu shots. The facility has sufficient PPEs.

ADM stated that they are allowing meals (staggered schedule) in their dinning area wherein they only accommodate 14 residents per table. The facility staff break can only allow 2 persons (staggered schedule). A random inspection of shared room wherein residents' beds are 6 feet apart. Discussed about Personal Protection Equipment (PPEs) wherein ADM was asked to demonstrate donning and doffing. Discussed about CCLD PINs 20-23, 20-38, 20-41 and PIN 20-42 with ADM.

During meeting, residents who are going into clinics or hospital, they have to remove their PPEs at the clinic/hospital prior to returning to the facility.

Please see Continuation 809-C
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2020
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: WESTGATE VILLA
FACILITY NUMBER: 435202759
VISIT DATE: 11/23/2020
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The following are Program Clinical Consultant (PCC) nurse recommendations:
1. Facility install a barrier at the reception area between visitors and staff.
2. Facility to use paper towel in the restrooms instead of cloth towel.
3. Facility to use paper towel holder for paper towels.
4. Facility to put a sign in the elevator door or next to the elevator that can only be use for one person at one time (unless a resident need to be accompanied by staff).
5. Facility to label (dates) all disinfecting solutions and the appropriate dilution of chemicals i.e., water and bleach (which is only good for 24 hours). All cleaning solutions has to be EPA approved
6. Facility to place signs on bins for soiled or wet and dry linens.
7. Facility ADM to conduct spot check of residents and staff on hand washing aside from daily in-service training.

No deficiencies cited during today's Tele Visit. A copy of this report is e-mailed to the facility for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2020
LIC809 (FAS) - (06/04)
Page: 2 of 2