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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294181
Report Date: 02/16/2021
Date Signed: 03/01/2021 11:25:46 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:PRUNERIDGE RESIDENTIAL CARE HOME, FACILITY #2FACILITY NUMBER:
435294181
ADMINISTRATOR:CORTES, LEILANI F.FACILITY TYPE:
740
ADDRESS:2575 FOREST AVENUETELEPHONE:
(408) 985-1982
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY:6CENSUS: 3DATE:
02/16/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Leilani CortesTIME COMPLETED:
02:05 PM
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Due to COVID-19 pandemic, Licensing Program Analyst (LPA) Yatfai Eric Ng partnered with Health Facilities Evaluator Nurse (HFEN) Marylene Majeska from the California Department of Public Health, conducted a tele-Case Management - Other via Zoom, to provide a technical assistance to prevent and mitigate the spread of COVID-19 at the facility. LPA and HFEN met with the Licensee (LIC) Leilani Cortes and staff members Maryann Villanueva and Lilibeth Taa holding the phone.

The virtual tour started at the entrance of the facility that had the signs to remind everyone to practice social distancing and wear masks. That was the entry and screening point for staff, essential workers, and family members of the residents. Staff demonstrated how the staff and visitors to check in before entering. LPA observed staff in the facility wore masks, face shields, and gowns at all time. Restrooms were toured that had soap and paper towels readily available. Residents had meals in their own rooms. Residents' clothes were washed with hot water separately. LPA and HFEN discussed with LIC what procedures to follow in isolating COVID-19 resident in his or her own room.

Following infection control practices were suggested:
  1. Post Provider Information Notice PIN 20-38-ASC to explain visitation limitation
  2. Post more signs in the common areas and in the break room to promote social distancing
  3. Use holder for paper towel
  4. Use garbage bin with lid for restroom
  5. Use disposable plates
  6. Watch video and read signs to learn to wear N95 mask properly

No deficiency cited during visit. This report was emailed to the LIC to review and to obtain signature. Additional resource about COVID-19 was also sent to LIC for reference.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2021
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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