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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202824
Report Date: 06/27/2022
Date Signed: 06/29/2022 07:59:34 AM

Document Has Been Signed on 06/29/2022 07:59 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:LYRIC LODGEFACILITY NUMBER:
435202824
ADMINISTRATOR:HAYES, JEFFREYFACILITY TYPE:
735
ADDRESS:1306 VINCI PARK WAYTELEPHONE:
(702) 510-9690
CITY:SAN JOSESTATE: CAZIP CODE:
95131
CAPACITY: 6CENSUS: 5DATE:
06/27/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Marissa NguyenTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Steve Chang, Licensing Program Manager (LPM) Romeo Manzano and Program Clinical Consultant (PCC) Christina Wong conducted Technical Assistant - PCC through tele-inspection (Zoom), and met with Administrator (ADM) Marissa Nguyen.

The purpose of this TA Tele visit was to review the facility COVID-19 infection mitigation plan and facility inspection of physical plant to ensure plan is being carried out, and to provide support and guidance to the staff in mitigating the spread of virus.

During tele-visit inspection, a tour of the facility was conducted which started at the main entrance to check COVID-19 signage and screening procedures. The facility has COVID-19 signage at the main entrance door, and screening station with the following: screening questionnaire, hand sanitizer, thermometer, face masks, and a visitor log.

The facility common areas were inspected such as the kitchen, living room, dinning area, and bathrooms.
Cloth towels were observed in kitchen and bathrooms. Some trash cans were observed without covers. Some paper towels were observed without holders. There are no washing hands signage with washing hands for 20 seconds by the sink in kitchen or restrooms. Three resident bedrooms were observed and inspected. One staff live-in room was observed in facility. Laundry area was observed and inspected. PPE supplies were observed sufficient.

Based on today's inspection, below are the recommendations:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2022
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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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: LYRIC LODGE
FACILITY NUMBER: 435202824
VISIT DATE: 06/27/2022
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1. Facility to have beds in shared rooms be 6 feet apart or to change the orientation of the beds.
2. Facility to have washing hands for 20 seconds posters by the sinks in the kitchen and restrooms.
3. Facility to have trash cans with covers.
4. Facility to remove the cloth towels in kitchen and restrooms.
5. Facility to have staff to do the N95 fitting test.
6. Facility to have signage of donning and doffing PPE by the PPE station.
7. Facility to wash the COVID negative first and last the COVID positive for laundry.
8. Facility to disinfect the washer and drier machine after the laundry for positive cases.
9. Facility to frequent wipe down common/ high touch areas with EPA grade disinfectants.
10. Facility to have facility staff wear N95 mask when taking care of positive resident.
11. Facility to use the highest temperature for positive cases’ laundry.
12. Facility to update the mitigation/infection control plan.
13. Facility to update the mitigation/infection control questionnaires,
14. PIN information: https://www.cdss.ca.gov/inforesources/community-care-licensing/policy/provider-information-notices/adult-senior-care.
15. https://youtu.be/CoSb-HJJ5tk - N95 - for seal check.
16. Facility to reference https://youtu.be/H4jQUBAlBrI - donning PPE.
17. facility to reference https://youtu.be/PQxOc13DxvQ - doffing PPE.

No deficiencies cited during today's Tele Visit. Exit interview conducted with ADM.
A copy of this report emailed to ADM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022
LIC809 (FAS) - (06/04)
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