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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200085
Report Date: 08/24/2022
Date Signed: 08/24/2022 05:09:04 PM

Document Has Been Signed on 08/24/2022 05:09 PM - 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:VILLA ANTONIOFACILITY NUMBER:
435200085
ADMINISTRATOR:JOSEPH ANTHONY OLIVAFACILITY TYPE:
740
ADDRESS:1494 KOCH LANETELEPHONE:
(408) 979-1757
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 6CENSUS: 5DATE:
08/24/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Dominica OlivaTIME COMPLETED:
10:10 AM
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Licensing Program Analyst (LPA) Christine Dolores conducted a scheduled technical assistance visit and met with Administrator, Tony Oliva and Dominica Oliva. LPA conducted a Facetime tour of the facility with Program Clinical Consultant (PCC), Roxane Fangon and Licensing Program Manager (LPM), Sarah Yip. The purpose of the visit was to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility.

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

1. Monitor the staff symptoms prior to starting their shift and throughout the day
2. Provide staff an in-service training to infection control to include donning and doffing PPE
3. Clean and disinfect the facility at least 3 times a day and as often as needed
4. Staff should don and doff PPE supplies when entering and exiting an isolation room
5. Provide a PPE cart and trash bin with lid next to the isolation room
6. The COVID positive resident's laundry should be done last and in the hottest setting. Have staff wear their PPE supplies when completing the COVID positive laundry. Clean and disinfect laundry area once done.
7. Complete the 10 day isolation period and monitor for symptoms on the 10th day
8. Thoroughly clean, disinfect, and aerate the facility after the isolation period

No deficiencies were cited per California Code of Regulations, Title 22.

This report was reviewed via telephone with Administrator, Tony Oliva and a copy of the report was emailed for signature.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2022
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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