435294328-12-18-2020-26-AS-GKUN-BWEVUM-20201218154459

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435294328
Report Date: 12/17/2020
Date Signed: 12/18/2020 03:45:17 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 FONTANA		FACILITY NUMBER:	435294328
ADMINISTRATOR:	DUEWEL, MA. FELICITAS V.		FACILITY TYPE:	740
ADDRESS:	5555 PROSPECT ROAD		TELEPHONE:	(408) 255-5555
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95129
CAPACITY:	104	CENSUS: 77	DATE:	12/17/2020
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Marife Duewel		TIME COMPLETED:	10:20 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Gladys Kuizon and Steve Chang conducted a Technical Assistance tele-inspection today and met with Administrator (AD) Marife Duewel. Community Care Licensing (CCL) Program Clinical Consultant (PCC) Helen Shi was present during tele-inspection. The facility currently has 18 residents in Memory Care (MC) and 59 residents in Assisted Living (AL). At 9:00 AM, the facility was toured starting from the main entrance of the building. LPAs reviewed the facility’s screening procedures with AD. The facility does not have an updated questionnaire screening form listing all known symptoms of COVID-19. On 07/02/20, the importance of up-to-date symptom checking and screening was discussed with AD during facility visit by the CA Department of Public Health (CDPH), Santa Clara County Public Health (SCCPH), and Community Care Licensing (CCL). On 07/15/20, PCC conducted a follow up discussion with AD regarding keeping up to date with COVID-19 related symptoms through the Centers for Disease Control (CDC)’s website and ensuring that a complete list of symptoms be included in the facility’s screening questionnaire. Today, facility was observed not following this recommendation as evidenced by a short list of COVID-19 related symptoms being used as part of the screening questionnaire. A sign-in sheet was observed in use. The facility’s common areas were observed. Hand sanitizers were observed accessible in the Assisted Living area. The facility had repurposed the ice cream parlor into a hand-washing area. The dining room was converted into a staff break room. Tables and chairs were observed spaced more than 6 feet apart. The common bathroom was equipped with covered trash bins and hand-washing posters were observed by the sink. Paper towels and soap were observed available. Continued, see LIC 809-C, page 2 of 3.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys Kuizon	TELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 FONTANA	FACILITY NUMBER: 435294328
	VISIT DATE: 12/17/2020

NARRATIVE

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At 9:41 AM, the memory care unit was toured. An isolation unit was observed separated by a curtain. Staff were observed wearing masks. Facility nurse (S1) demonstrated donning and doffing of isolation gown, shoe cover, gloves, and mask outside isolation room. S1 was observed posting door signs on residents, R1 and R2’s, rooms to warn staff of R1’s isolation status. According to AD, the facility received confirmation of R1 and R2’s positive COVID-19 test results on the evening of 12/16/2020. Based on LPAs’ observation, isolation rooms were not properly marked to alert staff of residents’ isolation status on the evening of 12/16/2020 and at the beginning of today’s shift.

According to AD, residents’ meals are being served in residents’ rooms or at staggered schedules for residents with cognitive impairment and behaviors. Memory Care dining room was configured to promote social distancing. Shared bedrooms were inspected, and beds were observed at least 6 feet apart.

Based on today's inspection, the facility is being recommended the following:

1. Keep up-to-date with current COVID-19 information, including COVID-19 related symptoms, by checking the Centers for Disease Control (CDC), local public health, and Community Care Licensing Division's websites. The most current information must be adapted into the facility's Infection Control and Mitigation Plan (e.g. screening).

2. Isolation rooms must be clearly marked upon knowledge of resident's positive diagnosis. Additionally, residents shall be placed in isolation and treated as positive prior to receipt of COVID-19 test results if resident is exhibiting COVID-19 related symptoms. A warning "STOP" sign to alert staff that full PPE is required prior to entry shall be placed on all isolation areas/rooms.

3. Facility shall place a covered trash bin inside and outside isolation rooms.

4. Common areas shall be sanitized after every use. This includes the staff break room.

Continued, see LIC 809-C, page 3 of 3.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys Kuizon	TELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2020

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 FONTANA	FACILITY NUMBER: 435294328
	VISIT DATE: 12/17/2020

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5. Facility to conduct a follow up training led by facility nurse regarding PPE donning and doffing. Proof of training shall be submitted to CCLD by 12/21/2020.

6. Facility shall send an updated Infection Control and Mitigation Plan to CCLD by 12/21/2020.

A deficiency is being cited today. See LIC 809-D. Exit interview was conducted with AD and a copy of this report was provided via email to AD for signature. Appeal rights provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys Kuizon	TELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2020

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 FONTANA	FACILITY NUMBER: 435294328
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/17/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/18/2020 Section Cited	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities. (a)(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
	8 9 10 11 12 13 14	Based on today's inspection, facility did not protect the personal rights of residents due to failure to follow current screening guidelines for COVID-19 including asking complete symptom list. This poses an immediate risk to the health and safety of residents in care.	8 9 10 11 12 13 14
Type A 12/18/2020 Section Cited	1 2 3 4 5 6 7	87307 Personal Accommodations and Services. (d)(3) All persons shall be protected against hazards...through provision of the following: (B) Information and instruction regarding life protection..This requirement was not met as evidenced by:
	8 9 10 11 12 13 14	Based on today's inspection, facility did not mark isolation rooms in a timely manner to protect residents and staff from entering COVID-19 positive room. This poses an immediate risk to the health and safety of residents in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys Kuizon	TELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2020

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2020

LIC809 (FAS) - (06/04)

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