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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294328
Report Date: 05/27/2021
Date Signed: 05/28/2021 07:56:07 AM

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: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: 78DATE:
05/27/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Marife DuewelTIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) arrived unannounced to conduct a Case Management Visit regarding COVID 19 Prevention Measures. LPA met with Marife Duewel Executive Director (ED) and toured the facility inside in out to include the Memory Care area.

The census is 78 of which 22 residents are in Memory Care. At the time of arrival, the facility was conducting staff surveillance testing. Per ED staff are tested 2 times per week and 25% of residents per week. This has been an ongoing standard of practice since 12/2020. The facility has not had any positive COVID 19 cases since this time.

LPA interviewed ED and one staff member, reviewed COVID 19 Mitigation Plan, resident records, and training records.

No citations issued per the California Code of Regulations Title 22.

Report reviewed with Marife Duewel and a copy emailed for signature due to technical issues.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021
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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