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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435601018
Report Date: 09/20/2021
Date Signed: 09/30/2021 08:16:27 AM

Document Has Been Signed on 09/30/2021 08:16 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
CCLD Regional Office,
, CA
FACILITY NAME:SAFE HAVEN VILLA CARE HOMEFACILITY NUMBER:
435601018
ADMINISTRATOR:THELMA LLANESFACILITY TYPE:
740
ADDRESS:5670 JUDITH STREETTELEPHONE:
(408) 809-4131
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 1DATE:
09/20/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Thelma LlanesTIME COMPLETED:
12:20 PM
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LPA Marybeth Donovan conducted a TA Visit with Cristina Wong Program Clinical Consultant (PCC), Sara Yip LPM, and Thelma Llanes Licensee/Administrator. The purpose of the visit was to provide technical assistance for Infection Prevention and Control guidelines for Adult and Senior Care facilities. LPA conducted a tour of the facility.

LPA and PCC reviewed the facility policies and procedures to include screening, visitation and social distancing, isolation, staffing, training, PPE usage, Doffing and Donning of PPE, Fit Testing, and disinfecting.

The following recommendations were discussed:

1. Post Signs in front of the facility to Do Not Enter for visitors and essential persons without staff screening.

2. Increase disinfecting of common areas and frequently touched surfaces to once per shift.

3. Continue ongoing staff training on infection prevention and control measures.

LPA provided Links to CDC printable posters, copies of the PPE Donning and Doffing and hand washing posters and Provider Information Notifications (PINs) 21-40 and 21-17.2 ASC.
RO to provide additional supply of PPEs to the facility.

LPA reviewed recommendations with Thelma Llanes Licensee/Administrator and copy emailed for signature.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Marybeth Donovan
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE:
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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