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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 440708773
Report Date: 12/28/2020
Date Signed: 12/28/2020 07:17:54 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:DOMINICAN OAKSFACILITY NUMBER:
440708773
ADMINISTRATOR:DEBORAH ROUTLEYFACILITY TYPE:
740
ADDRESS:3400 PAUL SWEET ROADTELEPHONE:
(831) 462-6257
CITY:SANTA CRUZSTATE: CAZIP CODE:
95065
CAPACITY:142CENSUS: 42DATE:
12/28/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Deborah RoutleyTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Gladys Kuizon conducted a Technical Assistance tele-visit today with Program Clinical Consultant (PCC) Roxane Fangon. LPA and PCC met with Administrator Deborah Routley.

At 11:46 AM, the facility was toured and the following recommendations were provided LPA and PCC:

1. Update facility's entrance screening procedures to ensure all individuals complete the screening process prior to passing through residents' rooms.

2. Place hand-washing guides which include the recommended 20-second duration on all hand-washing stations.

3. Furniture in common areas shall be configured in a way that promotes at least 6 feet of social distancing. Facility shall remove, mark, or move excess seating.

The facility has a scheduled facility-wide COVID-19 testing today.

These recommendations were discussed with Administrator. A copy of this report was provided to Administrator via email for signature.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2020
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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