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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294079
Report Date: 02/25/2021
Date Signed: 03/01/2021 11:44:00 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:RIVER PARK HOMES IIFACILITY NUMBER:
435294079
ADMINISTRATOR:GARCIA, AMPARO QUEFACILITY TYPE:
740
ADDRESS:3427 GILA DRIVETELEPHONE:
(408) 270-4060
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY:6CENSUS: 2DATE:
02/25/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Amparo GarciaTIME COMPLETED:
01:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Gladys Kuizon conducted a Case Management tele-visit today and met with Administrator Amparo Garcia. Due to COVID-19 restrictions, facility site visits have been suspended.

On January 27, 2021, Community Care Licensing Division (CCLD) received a written incident report from the facility notifying the Department that there was an outbreak of COVID-19 in the facility on December 27, 2020.

Based on records review and interview with Administrator, 1 staff member tested positive for COVID-19 on December 23, 2020. Administrator was contacted the same day by Santa Clara County Public Health Department (SCCPH) who had access to the positive test results. On December 27, 2020, another staff member tested positive. SCCPH scheduled a facility visit and conducted mass testing on January 9, 2021. By January 10, 2021, results of mass testing was received and 1 out of 2 residents was confirmed positive for COVID-19.

The Department received initial report of COVID-19 positive cases in the facility on January 27, 2021. As of report date, all residents and staff have recovered and have been cleared from isolation.

A deficiency was cited today. Please see LIC 809-D. This report was discussed with Administrator Amparo Que and a copy provided via email for signature.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2021
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: RIVER PARK HOMES II
FACILITY NUMBER: 435294079
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/26/2021
Section Cited

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87211 REPORTING REQUIREMENTS. (a)(2)Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents ...shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.
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This requirement was not met as evidenced by: The facility did not report an outbreak of COVID-19 in the facility, which started on 12/27/20, to licensing agency until 1/27/21. This posed a potential risk to the health & safety of residents in care.
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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: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2021
LIC809 (FAS) - (06/04)
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