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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202412
Report Date: 01/06/2021
Date Signed: 02/09/2021 09:50:29 AM

Document Has Been Signed on 02/09/2021 09:50 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:MERIDIAN MANOR 3 SPECIAL RES FAC FOR ELDERLY(RCFE)FACILITY NUMBER:
435202412
ADMINISTRATOR:DAVE MAGNOFACILITY TYPE:
740
ADDRESS:345 BURNETT AVE.TELEPHONE:
(408) 772-0339
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 4CENSUS: 4DATE:
01/06/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Dave Magno TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Karen Taku and Health Facilities Evaluator Nurse (HFEN) Mirabelle Villamin conducted a virtual tele-visit via ZOOM, to provide technical assistance to prevent and mitigate the spread of COVID-19 within the facility. LPA and HFEN met with Administrator Dave Magno.

During today's tele-visit, the following recommendations were made to the facility:

1. Screening Station: Sanitize pens after each use

2. Promote social distancing in the facility

3. Bathrooms should be stocked with paper towels at all times

4. Properly use and dispose of PPE: Gloves should be removed after each use

5. Soft toys/stuffed animals should be cleaned to prevent the spread of COVID

The report was reviewed the Administrator, and a copy was provided via email for signature.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Karen Taku
LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2021
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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