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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 355202348
Report Date: 09/21/2021
Date Signed: 09/22/2021 08:00:08 AM

Document Has Been Signed on 09/22/2021 08:00 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:CLEARVIEW CAREHOMES,INC.FACILITY NUMBER:
355202348
ADMINISTRATOR:FELICIDAD RAMOS KANKELBORGFACILITY TYPE:
740
ADDRESS:3370 CIENEGA ROADTELEPHONE:
(831) 637-4463
CITY:HOLLISTERSTATE: CAZIP CODE:
95023
CAPACITY: 6CENSUS: 3DATE:
09/21/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Felicidad Kankelborg, ADMTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Steve Chang, licensing Program Manager (LPM) Romeo Manzano, and Program Clinical Consultant (PCC) Kathleen Weiss conducted Technical Assistant -PCC through tele-inspection (Zoom), and met with Administrator (ADM) Felicidad Kankelborg and Evette Aguilar, Assistant Administrator..

The purpose of this TA PCC Tele visit was to review the facility COVID-19 infection mitigation plan and conducted inspection of the facility to ensure plan is being carried out and to provide support and guidance to staff in mitigating the spread of virus.

During tele-visit inspection, a tour of the facility was conducted which started at the main entrance to check COVID-19 signage and screening procedures. The facility has the COVID-19 posters at the main entrance. Hand sanitizer, face masks, thermometer, glove, and a visitor log book were observed at the screening station. The facility does not have the complete list of screening questionnaires at the screening station.

The facility common areas were inspected such as the kitchen, living room, family room, dining area, bathrooms were observed. No all the trash cans with cover were observed. Cloth towels were observed in kitchen and restrooms. No washing hands signage was observed by the sink in the kitchen and bathrooms. There are 5 bedrooms in facility including 1 staff live-in room, 2 empty rooms, 1 single room, and 1 shared room. There are 2 restrooms in the facility. Facility bathrooms signage on hand washing, hand sanitizer, paper towels were observed, and trash cans were observed. The laundry room was observed and inspected. The resident bedrooms were inspected. The beds in the shared rooms were observed in 6 feet apart. PPE supplies, and disinfect supplies were inspected.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2021
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: CLEARVIEW CAREHOMES,INC.
FACILITY NUMBER: 355202348
VISIT DATE: 09/21/2021
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ADM stated all the residents and staff are fully vaccinated. ADM stated the positive case staff is isolating at home. ADM stated tomorrow the facility will have another COVID test.

Facility staff demonstrated the donning and doffing of PPE. Facility staff demonstrated how to wash hands.

Based on today's inspection, the facility is being recommended the following:

1. Facility to wipe and disinfect high touch areas more often.

2. Kitchen towels and bath towels must be removed from the kitchen and bathrooms to avoid cross-contamination.

3. Recommend to use trash cans/bins with foot pedal in bathrooms and kitchen.

4. A signage on procedures of doffing and donning of PPEs in facility must be posted. CDC signage was provided to the facility.

5. Facility to review their mitigation plan on screening questionnaires. Facility to develop a screening questionnaires. LPA provided a sample of COVID-19 screening questionnaires.

6. Facility to maintain 6 feet social distancing during meals and activities in the facility.

7. ADM to post washing hands signs by the sink area in kitchen and bathrooms.


No deficiencies cited during today's Tele Visit. Exit interview conducted with Administrator. A Copy of this report emailed to the facility for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
LIC809 (FAS) - (06/04)
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