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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200006
Report Date: 03/29/2023
Date Signed: 03/29/2023 02:59:53 PM

Document Has Been Signed on 03/29/2023 02:59 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:SANTA CRUZ RESIDENTIAL CARE FACILITYFACILITY NUMBER:
019200006
ADMINISTRATOR:FRAINO, ANTHONYFACILITY TYPE:
735
ADDRESS:31360 SANTA CRUZ WAYTELEPHONE:
(510) 487-3905
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 5DATE:
03/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Lead Staff, Jorge SayganTIME COMPLETED:
03:15 PM
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On 3/29/2023 starting at 9:30 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct a 1-Year Annual Required Inspection. LPA met with Jorge Saygan, lead staff and explained the purpose of the visit. At 9:40 AM, Licensee, Anthony Fraino gave consent to lead staff to tour facility with LPA on licensees behalf. The facility’s fire clearance was approved for all six (6) ambulatory clients. Upon entry, LPA observed four (4) staff and five (5) clients present during inspection.

Starting at 9:55 AM, LPA toured facility with lead staff including but not limited to four (4) bedrooms, two (2) bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms which 2 bedrooms are private and 2 bedrooms are shared. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients'. The hot water temperature in clients’ shared bathroom was measured at 118.1 Degrees Fahrenheit. Clients’ bathrooms are equipped non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Sharps were locked and inaccessible to clients'.

Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was observed last serviced on 8/1/2022. First aid kit was observed to be complete.

Starting At 10:40 AM, LPA reviewed 4 of 4 staff records. At 11:15 AM, LPA reviewed 5 of 5 clients' record which are current. At 12:20 PM, LPA reviewed a sample of 5 of 5 clients' medications.


Continue on Lic809-C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: SANTA CRUZ RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 019200006
VISIT DATE: 03/29/2023
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Continued from Lic809

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 4/5/2023:
  • LIC 308 Designation of Administrative Responsibility
  • LIC 309 Administrative Organization
  • LIC 500 Personnel Report
  • LIC 610D Emergency Disaster Plan
  • Liability Insurance
  • Surety bond


Exit interview conducted with lead staff, and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
LIC809 (FAS) - (06/04)
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