435294334-2-23-2021-26-AS-JROA-BYHMZ8-20210223090244

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435294334
Report Date: 02/18/2021
Date Signed: 02/23/2021 09:03:12 AM

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 #3		FACILITY NUMBER:	435294334
ADMINISTRATOR:	CORTES, LEILANI F.		FACILITY TYPE:	740
ADDRESS:	312 LOWELL DRIVE		TELEPHONE:	(408) 504-1809
CITY:	SANTA CLARA	STATE: CA	ZIP CODE:	95051
CAPACITY:	6	CENSUS: 5	DATE:	02/18/2021
TYPE OF VISIT:	Case Management - COVID-19	UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Leilani Cortes		TIME COMPLETED:	04:30 PM

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 Analyst Joanne Roadilla and Health Facilities Evaluator Nurse (HFEN) Janet Hayes from the California Department of Public Health, conducted a tele-visit via Teams Meeting to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility. LPA and HFEN met with Licensee Leilani Cortes. At around 3:40pm, HFEN/LPA virtually toured the facility. COVID-19 related postings were visible at the entrance of the facility. There was a screening station by the front door. There were 2 staff present at the facility and both were observed wearing masks and face shields. HFEN/LPA recommended the following areas of infection control practices to prevent, contain, and mitigate the spread of COVID-19 at the facility: (1) N95s and face shields need to be worn in the facility by all staff and visitors until 2 consecutive rounds of mass testing are negative for any remaining residents or staff, who have not tested positive in the last 90 days. Gowns and gloves should also be worn in resident rooms. The county DPH will clear once this has happened. (2) Screening questions should be completed for all staff each day as they start their shift as well as any visitors. See screening form link. (3) Clean, new gowns and gloves should be put on before entering the room and should be thrown away before leaving the room. Gowns should not be reused and gloves should not be worn outside the residents rooms. Follow CDC guidance link. Continued on LIC809-C, page 2.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne Roadilla	TELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2021

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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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: PRUNERIDGE RESIDENTIAL CARE HOME #3	FACILITY NUMBER: 435294334
	VISIT DATE: 02/18/2021

NARRATIVE

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(4) Follow up to ensure response testing has been completed for all staff who have not tested positive in the last 90 days. As soon as possible after one (or more) COVID-19 positive individuals (resident or health care provider) is identified in a facility, serial retesting of all residents and staff who test negative upon the prior round of testing should be performed every seven days until no new cases are identified among residents in two sequential rounds of testing; the facility may then resume their regular screening testing schedule for staff.
(5) Once response testing is completed, surveillance testing of 25% of staff each week, who have not tested positive in the last 90 days.
(6) Ensure adequate supply of PPE, specifically N95s and gowns from CCL or local health department. If unable to receive enough additional N95s, plan to extend use wear of N95s for 3 days to ensure adequate availability. Place N95 in paper bag when not in use and discard after third day of wear. Dispose of gowns before exiting the room after completing care in COVID+ residents.
(7) Cleaning supplies used should be on the N List and the required wet time should be followed. See N List link.
(8) N95 should be worn without any additional masks.
(9) Rooms with COVID+ residents should be identified as isolation rooms.

The following links were provided by HFEN for facility reference:

SCREENING

CDC Screening tool
https://www.cdc.gov/screening/paper-version.pdf

PPE

Tying the face mask (once cleared and no longer need to wear N95)
https://www.youtube.com/watch?v=s3Y26UGulrI

Continued on LIC809-C, page 3.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne Roadilla	TELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2021

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: PRUNERIDGE RESIDENTIAL CARE HOME #3	FACILITY NUMBER: 435294334
	VISIT DATE: 02/18/2021

NARRATIVE

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SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne Roadilla	TELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2021

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: PRUNERIDGE RESIDENTIAL CARE HOME #3	FACILITY NUMBER: 435294334
	VISIT DATE: 02/18/2021

NARRATIVE

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Return to Work
https://www.cdc.gov/coronavirus/2019-ncov/hcp/return-to-work.html

CLEANING

N List - (use to see if cleaning products kill COVID and how long they need to stay wet)
https://www.epa.gov/pesticide-registration/list-n-disinfectants-coronavirus-covid-19

Pine-sol has to be used full strength and must remain fully wet for 10 minutes.

Bleach solution : Mix 1/3 cup bleach to 1 gallon of water. Mix fresh daily. Keep wet for 1 minute before wiping.

Other options, if needed, are ZEP (yellow alcohol based) and can be found at Home Depot, Walmart and Costco.

Vaccine Recs for Prior Exposure

https://www.cdc.gov/vaccines/covid-19/info-by-product/clinical-considerations.html

The Latest on the COVID-19 Vaccine (from Dr. Abdelnaby, LA County)

https://www.idsociety.org/multimedia/podcasts/the-latest-on-the-covid-19-vaccine/

No deficiencies cited during today's tele visit. This report was discussed with and a copy emailed to Leilani Cortes for signature.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne Roadilla	TELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2021

LIC809 (FAS) - (06/04)

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