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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275201863
Report Date: 08/31/2021
Date Signed: 08/31/2021 06:49:54 PM

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:ANJELICA'S VILLAFACILITY NUMBER:
275201863
ADMINISTRATOR:NERISSA RAMOSFACILITY TYPE:
740
ADDRESS:555 FRANCIS AVETELEPHONE:
(831) 899-2644
CITY:SEASIDESTATE: CAZIP CODE:
93955
CAPACITY:40CENSUS: DATE:
08/31/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:22 PM
MET WITH:Benjamin RamosTIME COMPLETED:
04:56 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 08/31/2021 at 03:22pm. LPA met with facility Administrator Benjamin Ramos (Admin).

LPA began touring the facility inside and out including living room, kitchen, dining room, office, 13 bathrooms, 20 bedrooms, 2 storage rooms, med room, laundry room, activities room, beauty shop, and patio. Facility temperature observed at 75 *F. Water temperature measured to be 116.3 *F All staff members observed to be wearing masks. Admin confirmed that all staff and residents have been vaccinated.

No prohibited items noted in resident rooms. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Hand sanitizers, soap, and paper supplies were observed to be available. All restrooms stocked with paper towels. Hand washing signs observed in all bathrooms. Social distancing signs observed to be posted in all public areas. LPA observed that no bathrooms had lidded trash cans. LPA told Administrator to replace trash cans in public areas with lidded, non-touch operable trash cans.

Facility observed to have designated entry point. Staff took LPA's temperature, screened for symptoms, and recorded information in visitor log. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. 30 day supply of PPE observed. Fire Extinguishers observed to have been serviced in August 2021. Carbon monoxide/smoke detectors were observed throughout the facility.

No deficiencies cited during today's visit. This report was reviewed with Administrator Benjamin Ramos and a copy of the signed report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
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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