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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202798
Report Date: 06/10/2022
Date Signed: 06/10/2022 10:20:29 AM

Document Has Been Signed on 06/10/2022 10:20 AM - It Cannot Be Edited

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:COPELAND HOUSEFACILITY NUMBER:
435202798
ADMINISTRATOR:CANLAS, AVELINO R JR.FACILITY TYPE:
735
ADDRESS:512 CENTURY OAKS WAYTELEPHONE:
(408) 823-7168
CITY:SAN JOSESTATE: CAZIP CODE:
95111
CAPACITY: 6CENSUS: 6DATE:
06/10/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Avelino CanlasTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) David Marrufo, Licensing Program Manager (LPM) Jackie Jin, and Program Clinical Consultant (PCC) Nurse Helen Shi conducted a tele-visit via Zoom to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility and met with Administrator Avelino Canlas.

Anna Zarragal reports that there are currently 4 COVID-19 positive residents and 0 COVID-19 positive staff.

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

1. Implement Visitor Symptom Screening Log at Entrance
2. Place PPE Donning and Doffing Instruction posters near Isolation Station/PPE Station
3. Place Isolation Station outside of the facility so staff can don PPE before entering facility
4. Remove cloths from kitchen; use only paper towels for drying surfaces and hands
5. Place sign at entrances advising visitors to wear masks.

No deficiencies were cited as per California Code of Regulations, Title 22.

This report was reviewed with Administrator Avelino Canlas. A copy of the report will be sent to them for it be signed and returned to CCL.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2022
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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