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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294181
Report Date: 05/20/2021
Date Signed: 05/28/2021 01:17:54 PM

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: 4DATE:
05/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:41 PM
MET WITH:Leilani CortesTIME COMPLETED:
04:55 PM
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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced infection control site visit today. LPA met with the Licensee Leilani Cortes.

LPA toured the facility with Licensee. One central entry point was designated for all staff, residents, and visitors. A screening station, sign in sheet, and COVID-19 questionnaire were present at the entrance. Hand sanitizer was present.

All staff members were observed to be wearing masks.

COVID-19 signs were present throughout the facility and hand washing signs in the restrooms. All restrooms observed to be adequately stocked with paper towels and hand soap. Bathrooms observed having foot pedal operated trash cans.

Facility observed to have adequate supply of PPE in the storage area. A plan for epidemic outbreak specific to COVID-19 mitigation plan report (LIC 808) was in file.

No deficiency cited during visit. However, an advisory note was issued, see LIC 9102.

This report was reviewed with Licensee and a copy of this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021
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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