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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200786
Report Date: 02/23/2022
Date Signed: 02/23/2022 05:06:14 PM

Document Has Been Signed on 02/23/2022 05:06 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:MERTZ CARE HOME IIIFACILITY NUMBER:
435200786
ADMINISTRATOR:JIMENEZ, Y. ROGELINEFACILITY TYPE:
740
ADDRESS:3928 THAINWOOD WAYTELEPHONE:
(408) 532-7020
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 3DATE:
02/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:JIMENEZ, Y. ROGELINETIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Christine Dolores conducted an unannounced annual required inspection to focus on infection control. LPA met with Administrator Rogeline Jimenez.

During today's visit, LPA toured the facility inside and outside to include entry way, dining room, resident rooms, bathroom, living room, kitchen, garage, and backyard. Fire exits were free and clear of obstruction.

LPA observed a central entry point and hand sanitizer for all visitors, residents, and staff. The following posters were observed to include, social distancing, visitor policy, symptoms of COVID, prevent the spread, cough etiquette, keep the facility clean, and hand washing. Bathrooms have supplies of paper towels and soap available for staff, residents, and visitors. Facility has enough PPE supplies. Facility disinfect and sanitize high touch surfaces multiple times daily and as needed. Staff and residents are observed to be wearing a mask. Facility has a mitigation plan in place to prevent the spread of COVID-19.

LPA reviewed facility procedures for isolation, screening, and N95 fit testing. LPA requested Administrator to send an updated LIC610D to CCLD.

No deficiencies cited during today's visit per California Code of Regulations, Title 22. Advisory Note provided.

This report was reviewed with Administrator Rogeline Jimenez and a copy of this report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2022
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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