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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294328
Report Date: 10/15/2020
Date Signed: 10/15/2020 03:30:07 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:VILLA FONTANAFACILITY NUMBER:
435294328
ADMINISTRATOR:DUEWEL, MA. FELICITAS V.FACILITY TYPE:
740
ADDRESS:5555 PROSPECT ROADTELEPHONE:
(408) 255-5555
CITY:SAN JOSESTATE: CAZIP CODE:
95129
CAPACITY:104CENSUS: 74DATE:
10/15/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Marife DuewelTIME COMPLETED:
10:00 AM
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Licensing Program Analysts(LPAs) Grace Davis and Steve Chang, conducted an unannounced Case Management via Facetime. Due to COVID-19 preventive measures, facility visits have been suspended. LPAs met with Administrator Marife Duewel.(AD)

The purpose of this visit was to conduct a facility tour to ensure that facility is continuing to adhere to COVID-19 infection control guidelines and preventive measures.

AD stated the facility had the second mass test for residents and staff on 10/14/2020 and the test results were all negative.

LPAs toured the 1st and second floor of the facility. LPAs observed COVID-19 posters in conspicuous areas in the facility. Hand sanitizer were observed available in the premises. LPAs observed nurse, front desk, medical clerk, and care givers are wearing face shield and mask. LPAs observed residents are wearing mask as well.
AD stated the dining room are not used, and meals are served at the resident rooms.

Per AD , Public Health nurse Lilian Tran visited the facility on 10/14/2020 . Lilian recommend that facility will go to surveillance test and the wearing of gowns is not necessary.

LPAs advised AD to continue to communicate with the Santa Clara County Health Department ad CA Department of Public Health for the most recent COVID 19 guidelines.

No deficiencies cited during today's Tele Visit. Exit Interview conducted with AD.
A copy of this report is e-mailed to the facility for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2020
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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