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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294212
Report Date: 01/27/2022
Date Signed: 01/27/2022 03:44:16 PM

Document Has Been Signed on 01/27/2022 03:44 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,
, CA
FACILITY NAME:PERPETUAL HELP CARE HOMEFACILITY NUMBER:
435294212
ADMINISTRATOR:CARUZ, VIRGILIO O.FACILITY TYPE:
740
ADDRESS:1888 ARROYO DE PLATINATELEPHONE:
(408) 258-1434
CITY:SAN JOSESTATE: CAZIP CODE:
95116
CAPACITY: 6CENSUS: 5DATE:
01/27/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Virgilio CaruzTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted a Technical Assist (TA) Visit via FaceTime with Virgilio Caruz Administrator, Sarah Yip Licensing Program Manager and Toni Rivera Program Clinical Consultant Nurse, to provide technical assistance to prevent and mitigate the spread of COVID 19 in the facility. LPA conducted a virtual tour of the facility.

During today's TA-Visit, recommendations were discussed as follows:

1. Notify Local Public Health of Positive case within 24 hours.
2. Post Sign to Wear Mask Before Entering the facility.
3. Complete Training on Donning and Doffing of PPEs.
4. Review OSHA Guidelines on N95 Fit Testing for staff.
5. Maintain COVID 19 Symptom Screening Log Sheet
6. Do not hang cloth towels in the bathrooms and maintain supply of paper towels available for use
7. Post Social Distance signs

LPA to forward CDC Posters for Donning and Doffing of PPE, Social Distancing, and informational Links on PPE usage and Provider information Notification (PIN) 22-04-ASC. Supply of PPEs to be provided to facility.

Report reviewed with Virgilio Caruz and copy emailed for signature.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Marybeth Donovan
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2022
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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