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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294334
Report Date: 12/29/2022
Date Signed: 12/29/2022 10:59:26 AM


Document Has Been Signed on 12/29/2022 10:59 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:PRUNERIDGE RESIDENTIAL CARE HOME #3FACILITY NUMBER:
435294334
ADMINISTRATOR:CORTES, LEILANI F.FACILITY TYPE:
740
ADDRESS:312 LOWELL DRIVETELEPHONE:
(408) 504-1809
CITY:SANTA CLARASTATE: CAZIP CODE:
95051
CAPACITY:6CENSUS: 5DATE:
12/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Staff Evelyn BriosoTIME COMPLETED:
11:15 AM
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On 12/29/2022 at 10:20am, Licensing Program Analyst (LPA) Simi Rai conducted an unannounced annual inspection focusing on infection control. LPA met with Staff Evelyn Brioso.

During visit, LPA Rai toured the facility to include the living room, 5 resident rooms, 3 bathrooms, 1 staff room, kitchen, laundry area, dining area and exterior. All fire exit routes are free and clear of obstruction. Toxins and sharp objects were secured. Disinfectants and laundry detergents stored in a locked cabinet.

Facility observed to have a designated central entry point to include a sign-in sheet and temperature check. Facility clean and disinfect twice daily and as often as needed. Bathrooms supplied with hygiene products and hand washing signs. Trash can with lid observed. LPA Rai observed Personal Protective Equipment (PPE) supplies were not sufficient for 30 days. Staff stated the facility will buy more PPEs. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient.

The following posters observed to include wash your hands, symptoms of COVID-19, social distancing and importance of wearing a mask.

No deficiencies were cited per California Code of Regulations, Title 22. Technical Advisory Note provided.

This report was reviewed with Staff Evelyn Brioso and a copy of the report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2022
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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