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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202827
Report Date: 06/09/2022
Date Signed: 06/10/2022 08:49:55 AM

Document Has Been Signed on 06/10/2022 08:49 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:SAN JOAQUIN HOME 2FACILITY NUMBER:
435202827
ADMINISTRATOR:LAUREL, PATRICK M.FACILITY TYPE:
735
ADDRESS:4790 CALLE DE TOSCATELEPHONE:
(408) 439-2636
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY: 6CENSUS: 5DATE:
06/09/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Patrick LaurelTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Steve Chang, Licensing Program Manager (LPM) Romeo Manzano and Program Clinical Consultant (PCC) Toni Rivera conducted Technical Assistant - PCC through tele-inspection (Zoom), and met with Administrator (ADM) Patrick Laurel .

The purpose of this TA PCC 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. There are 4 single resident bedrooms, 1 resident shared bedrooms, and 3 bathrooms at facility. Trash cans were observed with covers. Some paper towels were observed without holders. Washing hand posters were observed by the sink in restrooms and kitchen. Cloth towels were observed at kitchen and bathrooms, A gait belt was observed in one of the bathroom. ADM stated all the staff and residents are fully vaccinated and boosted

Based on today's inspection, below are the recommendations:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2022
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: SAN JOAQUIN HOME 2
FACILITY NUMBER: 435202827
VISIT DATE: 06/09/2022
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1. Facility to remove all washcloths, gait belt in bathrooms and kitchen area.
2. Facility to make sure that paper towels must be in paper towel holders.
3. Facility to post illustrations of hand washing with 20 seconds reminder.
4. Facility to make sure that hand sanitizer must be accessible and with supervision.
5. Facility to establish staggered dining times to maintain social distancing.
6. Facility to make sure Laundry hampers be lined with trash bags (black) and hampers with lid.
7. Facility to To wash the COVID negative first and last the COVID positive for laundry. Staff performing the laundry must be in full PPE (mask, face shield, gown and gloves) and wash in high temperature.
8. Facility to post the illustrated donning and doffing of PPE by residents doorway near close lid trash can.
9. Facility to frequent wipe down common/ high touch areas with EPA grade disinfectants.
10. Attend training (online/class) on Infection prevention control (IPC), PPEs conducted by CDC or the county public health.

Refer provider to the following PINs and CDPH recommendations:

1. PIN 22-16-ASC UPDATED DIAGNOSTIC AND RESPONSE TESTING GUIDANCE FOR CORONA VIRUS DISEASE 2019 (COVID-19).

2. PIN 22-14-ASC INFORMATIONAL CALL REGARDING CORONA VIRUS DISEASE 2019 (COVID-19) AND INFECTION CONTROL PLAN GUIDANCE.

3. PIN 22-13-ASC ADULT AND SENIOR CARE (ASC)- UPDATED REGULATIONS FOR INFECTION CONTROL REQUIREMENTS.

4. PIN 22-09-ASC UPDATED GUIDANCE ON QUARANTINE AND ISOLATION FOR FACILITY STAFF EXPOSED TO COVID-19 AND RETURN TO WORK FOR FACILITY STAFF WHO TEST POSITIVE FOR CORONA VIRUS DISEASE 2019 (COVID-19).
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
LIC809 (FAS) - (06/04)
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