435202759-6-23-2021-26-AS-CCHG-C49LDN-20210623084013

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202759
Report Date: 06/22/2021
Date Signed: 06/23/2021 08:41:12 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:	WESTGATE VILLA		FACILITY NUMBER:	435202759
ADMINISTRATOR:	TAYAG, AIDAH		FACILITY TYPE:	740
ADDRESS:	5425 MAYME AVENUE		TELEPHONE:	(408) 366-6510
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95129
CAPACITY:	60	CENSUS: 44	DATE:	06/22/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Aidah Tayag		TIME COMPLETED:	05:50 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	At 10:15AM, Licensing Program Analyst (LPA) Steve Chang and Licensing Program Manager (LPM) Romeo Manzano conducted an Annual Inspection and met with Administrator (ADM) Tayag Aidah and Residential Care Coordinator, Roselily Cacas. . Upon LPA/LPM entry to the facility, the facility main door was closed and its has to be opened by the facility staff. Staff conducted a COVID-19 infection screening prior to inspection such as body temperature intake and infection questionnaire; however, staff did not ask LPA/LPM to wash their hands. While LPA/LPM were waiting at the lobby, some staff who were coming in for surveillance testing were not washing their hands. During visit, the facility was conducting their COVID-19 weekly surveillance test. Activities for the residents were observed. LPA toured the facility inside and out. The facility room temperature was at 77 degree F. The facility hot water temperature was 109 degrees F (43 degrees C ). Residents' bedrooms were inspected and observed that their beds were 6 feet apart. Facility restrooms and bathrooms were inspected with electric paper towel dispenser and trash bins had covers. Hand sanitizers were observed in the entire facility (in hallways, main entrance, kitchen, and common areas) and COVID-19 signage or posters on both floors (main entrance, hallways, bathrooms, outside patio) were observed. LPA observed residents during lunch time wherein they were all 6 feet apart and 1-2 residents at one table. Food supplies were inspected, two day perishable and 7 day non-perishable foods were inspected and adequate. Continuation see LIC809-C

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

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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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: 06/22/2021

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At around 2 PM, when LPA/LPM returned back to the facility from lunch break, LPA/LPM were behind two staff (S1 and S2) who were entering/reporting in for their PM shift, these two staff were observed not washing their hands, and proceeded to walk within the facility.

A deficiency is being cited today. See LIC 809-D. Exit interview was conducted with ADM and Resident Care Director.

Due to technical issue (unable to print and no internet connection), evaluation reports including appeal rights will be e-mailed to Administrator tomorrow, 06/23/21. Administrator agreed and understood.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87468.1(a)(2)

Residents in all residential care facilities for the elderly shall have all of the following personal rights. (2) To be accorded safe, healthful and comfortable accommodations, furnishing and equipment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on today's inspection, some facility staff who were coming in for surviellance testing and reporting to work were observed not washing their hands and proceeded to walk within the facility.
	POC Due Date: 06/23/2021
	Plan of Correction
1 2 3 4	Adminstrator stated facility will conduct training on COVID-19 screening for all departments' staff and the facility will re-evaluate the facility infection mitigation plan. Administrator will submit evidence of staff training and addendum to their mitigation plan on screening (handwashing). POC is due by 06/23/2021.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

LIC809 (FAS) - (06/04)

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