435202864-5-31-2022-26-AS-CCHG-CEXSWE-20220531141413

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202864
Report Date: 05/31/2022
Date Signed: 05/31/2022 02:14:51 PM

Document Has Been Signed on 05/31/2022 02:14 PM - 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:	IFUR'S CARE HOME		FACILITY NUMBER:	435202864
ADMINISTRATOR:	MENDINUETO, VERONICA		FACILITY TYPE:	735
ADDRESS:	2861 LONGACRE COURT		TELEPHONE:	(408) 998-9020
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95121
CAPACITY: 6		CENSUS: 6	DATE:	05/31/2022
TYPE OF VISIT:	Case Management - COVID-19	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Ifur Batong		TIME COMPLETED:	09:39 AM

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	Licensing Program Analyst (LPA) Steve Chang, and Program Clinical Consultant (PCC) Kathleen Weiss conducted Technical Assistant - PCC through tele-inspection (Zoom), and met with House Manager (HM) Ifur Batong. The purpose of this TA PCC Tele visit was to review the facility COVID-19 infection mitigation plan and conducted inspection of the facility to ensure plan is being carried out and to provide support and guidance to 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 the COVID-19 posters at the main entrance. Screening station with screening questionnaire, hand sanitizer, thermometer, glove, and a visitor log was observed at the main entrance. The facility common areas were inspected such as the kitchen, living room, dinning area, bathrooms, and laundry area. There are 3 resident shared bedrooms, and 2 bathrooms at the first floor. There are 1 restroom, 1 office, and 1 storage room at the second floor. Trash cans were observed with covers. some Paper towels without holders were observed. The laundry room was observed and inspected. Cloth towels were observed in kitchen. One restroom was dedicated for positive cases. One restroom was dedicated for non-positive cases. Two resident bedrooms were dedicated for 4 positive residents. 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: 05/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022

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: IFUR'S CARE HOME	FACILITY NUMBER: 435202864
	VISIT DATE: 05/31/2022

NARRATIVE

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1. Facility to use disposable dishes and utensils for positive residents.
2. Administrator to review PINs on isolation.
3. Facility to have N95 fitting test for staff who are caring for positive residents.
4. Facility to do the laundry for negative residents first.
5. Facility to conduct staff training at least quarterly or as frequently as needed on
donning and doffing of PPE, COVID -19 updates by CDC, and/or local public
health and to review DSS-CCLD Providers Information Notice (PIN).
6. Facility to disinfect the high touched areas based on manufacture’s instruction on disinfection.
7. Facility to separate each resident's laundry load.
8. Facility to use the highest temperature for positive residents’ laundry.
9. Staff should be wearing N95 during this outbreak.
10. PIN information: https://www.cdss.ca.gov/inforesources/community-care-licensing/policy/provider-information-notices/adult-senior-care
11. Facility to have PPE station outside the isolation room.
12. Facility to have trash can with cover at the exit door of the isolation room.
13. Facility to have washing hands for 20 seconds posters by the sink in kitchen and restrooms.
14. Facility to have all the paper towels with holders.

No citation were noted during today's Tele Visit. Exit interview conducted with HM.
A copy of this report emailed to HM for signature.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022

LIC809 (FAS) - (06/04)

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