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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294143
Report Date: 12/02/2020
Date Signed: 01/04/2021 11:08:02 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:SOUTH COUNTY RETIREMENT HOME INC.FACILITY NUMBER:
435294143
ADMINISTRATOR:APOSTOL, SAMUEL C.FACILITY TYPE:
740
ADDRESS:460 CHURCH AVENUETELEPHONE:
(408) 683-0229
CITY:SAN MARTINSTATE: CAZIP CODE:
95046
CAPACITY:46CENSUS: 44DATE:
12/02/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Tamara Keo and EliaserTIME COMPLETED:
02:15 PM
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LPA Steve Nguyen, LPA Jackie Jin, and PCC Paul Portem conducted a virtual Technical Assistance with Direct Care Staff, Tamara Keo and Direct Care Staff, Eliaser Apostol. The tele-visit consisted of a virtual tour of the facility and LPA advised Direct Care Staff that the purpose of the visit was to provide guidance and assistance with the COVID-19 Infection Control and Mitigation procedures.

The tour showed that the facility main entrance had signs informing all visitors, staff and residents of Covid protocols. Observed sign-in station with digital thermometer and hand sanitizer at entrance. The facility furthermore had sufficient COVID-19 signage throughout the facility. Restroom were observed clean and with paper towels. Hand sanitizing station were available throughout the facility. Additionally, the facility had ample PPE's on hand. Staff and residents were observed wearing face masks and when necessary, observed staff redirect residents to wear masks. Staff encourages residents to social distance when necessary and dining room's furniture was properly spaced out to maintained social distancing protocol. Isolation room had proper Covid signs posted and proper disposal of PPE was outlined.

Based upon the observation during the inspection, the following guidance was issued:
• Facility staff instructed to place hand washing instructions with pictures of how to wash hands properly in the English language by the kitchen sink. Facility staff also instructed to always perform hand hygiene and utilized alcohol hand rub if not near a sink with running water and liquid soap.
* Facility staff instructed to purchase paper towel rolls when available.

END OF REPORT
SUPERVISOR'S NAME: George NwaforTELEPHONE: (408) 324-2116
LICENSING EVALUATOR NAME: Steve NguyenTELEPHONE: (650) 676-0051
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE:
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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