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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200006
Report Date: 03/19/2024
Date Signed: 03/19/2024 06:18:12 PM

Document Has Been Signed on 03/19/2024 06:18 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:
03/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Jorge SayganTIME COMPLETED:
06:35 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection and met with staff Jorge Saygan. LPA explained to Saygan the purpose of the visit. LPA and Saygan contacted the Administrator who authorized Saygan to sign the report.

During the visit, LPA inspected the facility inside and out including but not limited to bedrooms, bathrooms, kitchen, dining, garage and outside areas. The facility is a Level 4i home vendorized by the Regional Center of the East Bay (RCEB). LPA observed a fire extinguisher in the kitchen that appeared full and was last serviced on 8/28/2023. Smoke detectors and carbon monoxide detectors were tested and observed functional. There were sufficient supply of both perishable and non perishable foods. The facility has ample supply of warm blankets, sheets and towels available for use of the clients. First aid kit was inspected and observed complete and updated. Medications were observed locked in a cabinet. Hot water in the kitchen and bathroom measured at 105 degrees Fahrenheit.

LPA interviewed 2 staff and 2 clients. LPA reviewed 5 staff and 5 client files. All staff were observed fingerprint cleared and associated to the facility. Staff have current First Aid and CPR training except for S3 who is missing proof of First aid training. P&I money and log were checked. LPA observed the facility has sufficient amount of surety bond to cover amount of money being handled at one time. The facility's last fire drill was conducted on 3/7/2024 and last earthquake drill was completed on 12/17/2023. LPA reviewed medications and Medications Administration Records(MAR) with Saygan.

The following deficiencies were observed: Missing wood planks in the backyard fence, screen window in the kitchen not fitting, side gate on one side is hard to open, one couch is caving in and bathroom bulb needed replacement, S3 is missing proof of first aid training.
continuation on Lic 809C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: SANTA CRUZ RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 019200006
VISIT DATE: 03/19/2024
NARRATIVE
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Deficiencies are cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty.

Exit interview was conducted and Appeal Rights was provided with Saygan.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
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Document Has Been Signed on 03/19/2024 06:18 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 03/19/2024 at 05:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SANTA CRUZ RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 019200006

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80010(b)
Limitations on Capacity and Ambulatory Status
(b) Facilities or rooms approved for ambulatory clients only shall not be used by nonambulatory clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in not having C1 use Room #1 which is approved for ambulatory which poses an immediate health, safety or personal rights risk to persons in care. C1 currently uses a walker, walks slowly and needs staff assistance during evacuation.
POC Due Date: 03/22/2024
Plan of Correction
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The Administrator will notify fire department regarding C1 occupying an ambulatory room and submit proof to CCL within 24 hours. The Administrator will issue a 30-day notice to C1 and send a copy to LPA by Friday 3/22/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/19/2024 06:18 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 03/19/2024 at 05:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SANTA CRUZ RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 019200006

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having a fence with missing wood planks, screen window not fitted, etc. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/02/2024
Plan of Correction
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By POC date, Administrator will repair/fix screen window, side gate, etc and submit photo proof.
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review, the licensee did not comply with the section cited above in not having proof of first aid for S3 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2024
Plan of Correction
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S3 will take first aid class and submit proof to CCL by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024


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